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David  Jl^.  Levy 
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^     THE      \ 
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BENIGN  STUPORS 


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THE    MACMILLAN    COMPANY 

NEW  YORK    •    BOSTON   •    CHICAGO   •    DALLAS 
ATLANTA    •    SAN  FRANCISCO 

MACMILLAN  &  CO.,  Limited 

LONDON   •    BOMBAY    •    CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA,  Ltd. 

TORONTO 


BENIGN  STUPORS 

A   STUDY  OF 
A    NEW    MANIC-DEPRESSIVE    REACTION     TYPE 


BY 

AUGUST    HOCH,    M.D. 

LATE     DIRECTOR     OP^     THE     PSYCHIATRIC     INSTITUTE     OF     THE 

NEW     YORK     STATE     HOSPITALS,     WARD's     ISLAND,     NEW 

YORK.     LATE    PROFESSOR  OF  PSYCHIATRY,  CORNELL 

UNIVERSITY    MEDICAL    COLLEGE,    NEW    YORK 


jQeto  gotfe 

THE  MACMILLAN  COMPANY 

1921 


AU  rigtUa  reserved 


FEINTED   IN   THE   UNITED    STATES    OF   AMERICA  .   /V'>  i 

1  7  ol\ 


COPYKIGHT,   1921, 

By  the  MACMILLAN  COMPANY 
Set  up  and  printed.    Published  July,  1921. 


^ 


Press   of 

J.   J.   Little  &   Ives   Company 

New  York,  U.  S.  A. 


TO 

MY  FORMER   COLLEAGUES 

IN   THE 

NEW  YORK  STATE  HOSPITAL  SERVICE 


EDITOE'S  PREFACE 

A  word  should  be  said  as  to  the  origin  and  history 
of  this  book.  When  the  late  Dr.  Hoch  became  Di- 
rector of  the  Psychiatric  Institute  of  the  New  York 
State  Hospitals  in  1910,  he  found  there  an  interest 
in  just  the  kind  of  psychiatric  research  which  it  was 
his  ambition  to  further.  His  predecessor,  Adolf 
Meyer,  had  developed  the  conception  that  the 
psychoses  should  be  looked  on  as  psychobiological 
reactions  rather  than  rigid  nosological  entities  and 
had  inculcated  the  habit  of  scrupulously  thorough 
examination  and  record  of  what  the  patient  said  and 
did.  Meyer  had  broken  away  from  the  sterile  habit 
of  making  diagnoses  in  accordance  with  the  set  terms 
used  to  label  symptoms;  and  his  work  and  that  of 
his  assistants  thus  led  to  a  collection  of  valuable 
material  which  could  serve  as  a  useful  starting  point 
for  the  keen  clinical  investigation  of  Hoch.  Spe- 
cifically, attention  had  already  been  fixed  on  the 
study  of  the  so-called  functional  psychoses,  compris- 
ing what  are  generally  termed  Dementia  Prsecox  and 
Manic-Depressive  Insanity.  An  urgent  problem  in 
this  field  was  to  separate  different  reaction  types  in 
order  to  discover  which  were  recoverable  and  which 
chronic  or  progressive.  In  order  to  understand 
psychological   reactions,   interrelation   rather   than 

vii 


viii  EDITOR'S  PREFACE 

mere  coincidence  of  symptoms  must  be  studied  and, 
to  aid  in  this,  free  use  was  made  of  the  fundamental 
principles  of  unconscious  mentation  as  exposed  in 
the  theories  of  Freud  and  his  followers. 

Almost  at  the  outset  it  had  been  discovered  that 
many  patients  presented  clinical  pictures  that  would 
not  fit  into  existing  diagnostic  pigeon  holes.  Dr. 
George  H.  Kirby,  whose  skill  and  industry  had  made 
the  most  valuable  contributions  to  the  archives  of 
the  Institute,  published  in  1913  a  brief  paper  in 
which  he  pointed  out,  not  only  that  many  cases  with 
*' catatonic"  symptoms  recovered,  but  also  that  clin- 
ically the  behavior  of  stupor  showed  it  to  be  related 
to  manic-depressive  insanity  as  well  as  dementia 
prsecox.  Dr.  Hoch  took  up  the  problem  at  this  point. 
Using  Dr.  Kirby 's  material  and  adding  to  it  his 
earlier  observations  as  well  as  current  cases,  he  en- 
deavored to  work  out  the  essentials  of  the  stupor  re- 
action. It  was  his  ambition  to  describe  stupor  not 
only  in  its  psychiatric  bearing  but  also  as  a  life 
reaction. 

The  significance  of  this  task  is  to  be  realized  only 
when  one  considers  the  general  import  of  the  func- 
tional psychoses.  They  are,  biologically,  failures 
of  adaptation.  The  chronic  and  deteriorating  cases 
give  up  the  struggle  permanently,  while  the  tempo- 
rary insanities  lay  bare  the  soul  of  man  as  he  catches 
a  glimpse  of  unreality  but  turns  back  to  face  the 
world  as  it  is.  When  one  realizes  that  emotional 
disturbances  are  characteristio  of  the  benign  psy- 
choses, it  is  easy  to  imagine  how  much  such  studies 


EDITOR'S  PREFACE  ix 

may  ultimately  illuminate  the  problems  of  normal 
life. 

The  technical  value  of  this  work  to  psychiatry  is 
more  immediate.  Kraepelin  laid  the  foundations  for 
systematic  classification  with  his  dementia  prsecox 
and  manic-depressive  groups.  But  the  rigidity  of 
the  latter,  allegedly  descriptive,  term  has  confused 
the  problem  of  classifying  many  benign  psychoses. 
It  was  Hoch's  ambition  to  prove  that,  although  ela- 
tion and  depression  were  the  commonest  mood 
anomalies  in  this  group,  they  had  no  more  theoretic 
importance  than  anxiety,  distressed  perplexity  or 
apathy.  These  other  moods,  although  less  frequent, 
are  just  as  characteristic  of  the  psychoses  in  this 
group.  In  other  words,  the  name  ^'Anxiety- 
Apathy  Insanity''  would  be  as  appropriate,  theo- 
retically, as  Kraepelin 's  term.  In  1919  Hoch  and 
Kirby  published  a  report  on  the  perplexity  cases. 
This  present  book  was  designed  to  show  that  the 
symptom  complex  centering  around  apathy  is  as  dis- 
tinct as  that  which  is  recognized  by  all  psychiatrists 
as  mania  with  its  predominant  characteristic  of 
elation. 

In  1917  ill  health  forced  Dr.  Hoch  to  resign  from 
his  official  duties.  He  retired  to  California  with  the 
purpose  of  adding  to  psychiatric  literature  the 
fruits  of  his  long  experience  and  unrivaled  judg- 
ment. His  first  task  was  this  book.  In  the  midst  of 
this  work  came  a  sudden  collapse.  As  I  had  been  in 
close  touch  with  his  researches,  cooperating  in 
psychological  speculations,  and  was  free  to  devote 


X  EDITOR'S  PREFACE 

some  time  to  it,  lie  asked  shortly  before  his  death 
that  I  complete  the  book.  This  obligation  is  incom- 
mensurate with  the  debt  I  owe  for  years  of  inspira- 
tion, tuition  and  criticism. 

The  task  has  been  mainly  literary.  I  found  the 
first  ^ve  chapters  practically  completed,  while  it  has 
not  been  difficult,  as  a  rule,  to  discover  from  his 
copious  notes  what  his  intentions  were  as  to  the 
details  of  the  following  chapters.  I  have  been 
greatly  aided  by  the  assistance  of  Dr.  Adolf  Meyer 
and  of  Dr.  Kirby.  The  latter  has  been  good  enough 
to  read  the  entire  manuscript,  making  invaluable 
suggestions  and  criticisms. 

John  T.  MacCukdy. 

New  York. 


TABLE  OF  CONTENTS 

CHAPTER  PAGH 

Editor's  Preface vii 

I.    Introduction  and  Typical  Cases  of  Deep 

Stupor    1 

II.     The  Partial  Stupor  Reactions      ....  34 

III.  Suicidal  Cases 50 

IV.  The  Interferences  with  the  Intellectual 

Processes 67 

V.     The  Ideational  Content  of  the  Stupor     .  82 

VI.     Affect 123 

VII.     Inactivity,  Negativism  and  Catalepsy         .  132 

VIII.     Special  Cases:  Relationship  of  Stupor  to 

Other  Reactions 149 

IX.     The  Physical  Manifestations  of  Stupor    .  174 

X.    Psychological  Explanation  of  the  Stupor 

Reaction 186 

XI.    Malignant  Stupors 205 

XII.     Diagnosis  of  Stupor 223 

XIII.  Treatment  of  Stupor 229 

XIV.  Summary  of  the  Stupor  Reaction    .     .     .  234 
XV.     The  Literature  of  Stupor 249 

Index 279 

xi 


BENIGN  STUPORS 

CHAPTEE  I 

INTRODUCTION  AND  TYPICAL  CASES  OF  DEEP  STUPOR 

The  fact  that  psychiatry  lags  in  development  and 
recognition  behind  other  branches  of  medicine  is  due 
in  part  to  the  crudity  of  its  clinical  methods.    The 
evolution    of    interest   in    science   is   from    simple, 
obvious  and  tangible  problems  to  more  intricate  and 
impalpable  researches.  Eefined  laboratory  work  has 
been  done  in  psychiatric  clinics,  particularly  along 
histopathological  lines,  but  clinical  studies  follow 
antequated  methods.     The  internist  does  not  say, 
^^The  patient  has  sugar  in  his  urine,  therefore  he 
has  diabetes  and  therefore  he  will  die."    He  finds  a 
glycosuria  and  looks  for  its  cause.    If  this  symptom 
is  found  to  be  related  to  others  in  such  a  way  as  to 
justify   the    diagnosis    of    diabetes,    a   therapeutic 
problem  arises,  that  of  adjusting  the  chemistry  of 
the  body.    The  prognosis  depends  not  on  the  disease 
but  the  interreaction  of  the  organism  and  the  morbid 
process.    Both  in  diagnosis  and  treatment  an  indi- 
vidual factor,  the  patient's  metabolism,  is  of  prime 
importance.    Now  in  psychiatry,  although  the  per- 
sonality is  diseased,  this  personal  factor  has  been 


2  BENIGN  STUPORS 

almost  entirely  neglected.  Text-books  furnish  us 
with  composite  pictures  which  are  called  diseases, 
not  with  descriptions  of  reactions  brought  about  by 
the  interplay  of  personal  and  environmental  factors. 
Educated  people  are  not  satisfied  with  novels  that 
fail  to  depict  real  characters.  Clinical  psychiatry, 
however,  has  been  content  with  the  dime-novel  type 
of  character  delineation.  This  is  all  the  more  disap- 
pointing, inasmuch  as  the  study  of  insanity  should 
contribute  largely  to  our  knowledge  of  everyday  life. 
This  defect  can  only  be  remedied  by  looking  on  every 
case  as  a  problem  in  which  the  origin  of  each  symp- 
tom is  to  be  studied  and  its  relation  traced  to  all 
other  symptoms  and  to  the  personality  as  a  whole. 
This  is  an  ambitious  task  and  we  do  not  pretend  to 
any  great  achievement,  merely  to  a  beginning. 

No  better  psychoses  could  be  chosen  for  a  prelimi- 
nary effort  than  benign  stupors.  Every  psychiatrist 
has  seen  them,  although  they  are  wrongly  diagnosed 
as  a  rule,  and  they  play  no  small  role  in  the  world's 
history.  Euripides  represents  Orestes  as  having  a 
stupor  which  is  pictured  as  accurately  as  any  mod- 
ern psychiatrist  could  describe  an  actual  case.^  St. 
Paul  is  chronicled  as  falling  to  the  ground,  being 
thereafter  blind  and  going  without  food  or  drink  for 
three  days.  While  apparently  unconscious  he  had 
a  religious  vision.  St.  Catherine  of  Siena  had  sev- 
eral unquestionable  stupors,  which  are  fairly  well 

*  MacCurdy  has  discussed  the  psychological  phenomenon  of  a 
flramatist  depicting  a  psychosis  correctly  in  ''Concerning  Hamlet 
and  Orestes."     Jouriml  of  Abnormal  Psychology,  Vol.  XIII,  No.  5. 


TYPICAL   CASES  OF  DEEP   STUPOR  3 

described.  In  fact  the  mystics  in  general  seem  to 
have  had  communion  with  God  and  the  saints  most 
often  when  they  seemed  unconscious  to  bystanders.^ 
The  obsession  with  death,  which  seems  so  intimate 
a  part  of  the  stupor  reaction,  is  a  fundamental  theme 
in  poetry,  religion  and  philosophy.  The  psychology 
of  this  interest  is,  speaking  broadly,  the  psychology 
of  stupor.  So,  from  a  general  standpoint,  our  prob- 
lem is  related  to  the  study  of  one  of  the  most  potent 
ideas  which  move  the  soul  of  man. 

Psychiatrically,  stupors  have  long  remained  an 
unsolved  riddle.  In  the  century  prior  to  1872  (See 
the  digest  of  Dagonet's  publication  in  Chapter  XV) 
French  psychiatrists  wrote  some  good  descriptions 
of  stupor  and  offered  brilliant,  though  sketchy  gen- 
eralizations about  the  condition.  Two  years  later 
an  English  psychiatrist  (Newington,  See  Chapter 
XV)  improved  on  the  French  work.  Little  light  has 
been  thrown  on  the  subject  since  then.  The  re- 
searches of  the  later  French  School  showed  that 
stupor  often  occurs  in  the  course  of  major  hysteria, 
but  this  left  many  of  these  episodes  obviously  not 
hysterical.  When  serious  attempts  were  made  at 
classification,  this  ubiquitous  symptom  complex  was 
hard  to  handle.  Wernicke  wisely  refrained  from 
attempting  more  than  a  loose  descriptive  grouping. 
He  called  all  conditions  with  marked  inactivity  and 

^Many  of  these  states  seem  to  be  hysterical  rather  than  manic- 
depressive  stupors,  but  so  far  as  the  unconsciousness  goes,  there  is 
probably  as  much  psychological  as  symptomatic  resemblance  be- 
tween the  two  types  of  reaction. 


4  BENIGN  STUPORS 

apatliy  "akinetic  psychoses''  and  said  that  some 
recovered,  some  did  not.  Taxonomic  zeal  began  to 
blind  vision  when  Kahlbaum  formulated  his  ' '  Cata- 
tonia'' and  included  stupor  in  the  symptom  complex. 
The  condition  which  we  call  stupor  occurs  in  the 
course  of  many  different  types  of  mental  disease. 
It  is  true  that  it  is  frequent  in  catatonia  but  is  not 
exclusively  there.  Mongols  have  black  hair  and 
straight  hair,  but  one  cannot  therefore  say  that  any 
black  and  straight  haired  man  is  a  Mongol.  Fortu- 
nately Kahlbaum  prevented  serious  error  by  leaving 
the  prognosis  of  his  catatonia  open.  When  Kraepe- 
lin  included  it  in  his  large  group  of  Dementia 
praecox,  however,  it  implied  that  stupor  could  not 
be  an  acute,  recoverable  condition.^  He  unquestion- 
ably advanced  psychiatry  greatly  but  his  scheme  was 
too  ambitious  to  be  accurate.  Many  observers  saw 
patients,  classified  as  dements  according  to  Kraepe- 
lin's  formulae,  return,  apparently  normal,  to  normal 
life.  Finally  Kirby^  published  a  series  of  cases 
which  showed  decisively  that  this  classification  was 
too  rigid. 

Since  his  paper  is  the  foundation  for  this  present 
study,  it  should  be  reviewed  carefully.  He  first 
points   out  that  Kraepelin's   '* Dementia  praecox'' 

'  Kraepelin  recognizes,  of  course,  the  occurrence  of  stupor  symp- 
toms or  states  in  the  course  of  manic-depressive  psychoses.  It  is 
stupor  as  a  clinical  entity,  as  a  separate  psychosis,  that  he  regards 
as  one  form  of  the  catatonic,  and  therefore  of  the  dementia  prascox, 
reaction, 

*Kirby,  George  H. :  ''The  Catatonic  Syndrome  and  Its  Relation 
to  Manic-Depressive  Insanity."  Jour,  of  '^Nervous  and  Mental  Dis- 
ease, Vol.  40,  No.  11,  1913. 


TYPICAL   CASES  OF  DEEP  STUPOR  5 

includes  much  more  than  it  should  with  its  inevitably 
bad  prognosis.  He  shows  how  others  have  found 
patients  with  catatonic  symptom  complexes  proceed 
to  recovery  and  speaks  of  these  symptoms  occurring 
in  epilepsy  and  even  in  frankly  organic  conditions, 
such  as  brain  tumor,  general  paralysis,  trauma  and 
infections.  Kirby's  first  claim  is  that  there  are 
probably  fundamentally  different  catatonic  pro- 
cesses, deteriorating  and  non-deteriorating.  Lack 
of  knowledge  has  prevented  us  from  understanding 
the  meaning  of  the  symptoms  and  hence  making  the 
discrimination.  He  points  out  that  stupor  seems  to 
represent  an  attitude  of  defense,  similar  to  feigned 
death  in  animals,  and  that  in  a  number  of  his  cases 
it  was  clear  that  the  stupor  symbolized  the  death  of 
the  patient.  Apparent  negativism,  he  found  to  be 
often  a  consciously  assumed  attitude  of  aversion 
towards  an  unpleasant  emotional  situation.  In 
cases  where  there  had  been  no  prodromal  symptoms 
pointing  definitely  to  dementia  praecox  the  outcome 
was  almost  always  good.  To  discriminate  the  cases 
with  good  outlook  from  those  with  bad,  he  discerned 
no  difference  in  the  stupors  themselves,  but  ob- 
served that  the  mental  make-up  and  initial  symp- 
toms differed  sufficiently  for  diagnosis  to  be  made. 
His  most  important  point  is,  perhaps,  that  these 
benign  stupors  showed  a  definite  relationship  to 
manic-depressive  insanity  in  that  some  patients 
passed  directly  from  stupor  to  typical  manic  excite- 
ment, while  in  others  a  *' catatonic"  attack  replaced 
a  depression  in  a  circular  psychosis. 


6  BENIGN  STUPORS 

Kirby  introduces,  then,  the  idea  of  stupor  being  a 
type  of  reaction  which  can  occur  either  in  dementia 
praecox  or  in  manic-depressive  insanity.  The  mat- 
ter cannot  be  left  there,  in  fact  it  raises  new 
problems:  what  constitutes  the  reaction?  how  are 
the  various  symptoms  interrelated?  are  they  differ- 
ent in  deteriorating  and  acute  cases?  what  is  the 
teleological  significance  of  the  reaction?  if  it  be  an 
integral  part  of  the  manic-depressive  group,  how 
does  it  affect  our  conceptions  of  what  manic-depres- 
sive insanity  is?  More  than  five  years  have  been 
spent  in  endeavors  to  answer  these  questions  and  the 
results  of  the  study  are  now  presented. 

Naturally  the  first  point  to  be  settled  is:  what 
constitutes  the  stupor  reaction  itself.  We  can  say  at 
the  outset  that  it  is  seen  in  the  purest  form  in  benign 
cases,  hence  they  make  up  the  material  of  this  book. 
To  discover  the  symptoms  of  the  disorder  one 
cannot  do  better  than  to  study  them  in  their  most 
glaring  form  in  deep  stupors,  where  consistently 
recurring  phenomena  may  be  assumed  to  be  essen- 
tial to  the  reaction. 

Case  1. — Anna  G.  Age:  15.  Admitted  to  the  Psychiatric 
Institute  July  25,  1907. 

F.  H.  The  mother  and  two  brothers  were  living  and  said  to 
be  normal.  The  father  died  of  apoplexy  when  the  patient  was 
seven. 

P.  H.  The  patient  was  sickly  up  to  the  age  of  seven,  but 
stronger  after  that.  It  is  stated  that  she  got  on  well  at  school, 
though  she  was  somewhat  slow  in  her  work.  She  was  inclined 
to  be  rather  quiet,  even  when  a  child,  a  bit  shy,  but  she  had 
friends  and  was  well  liked  by  others.     After  recovery  she  made 


TYPICAL   CASES  OF  DEEP   STUPOR  7 

a  frank,  natural  impression.  She  was  always  rather  sensitive 
about  her  red  hair.  She  began  to  work  a  year  before  admission 
and  had  two  positions.  The  last  one  she  did  not  like  very  well, 
because,  she  alleged,  the  girls  were  "too  tough." 

Three  weeks  before  admission  she  came  home  from  work  and 
said  a  girl  in  the  shop  had  made  remarks  about  her  red  hair. 
She  wanted  to  change  her  position,  but  she  kept  on  working 
until  six  days  before  admission.  At  that  time  her  mother  kept 
her  at  home  as  she  seemed  so  quiet,  and  when  the  mother  took 
her  out  for  a  walk  she  wanted  to  return,  because  "everybody 
was  looking"  at  her.  For  the  next  two  days  she  cried  at  times, 
and  repeatedly  said,  "Oh,  I  wish  I  were  dead — nobody  likes 
me — I  wish  I  were  dead  and  with  my  father"  (dead).  She  also 
called  to  various  members  of  the  family,  saying  she  wanted  to 
tell  them  something,  but  when  they  came  she  would  only  stare 
blankly.  For  a  day  she  followed  her  mother  around,  clung  to 
her,  said  once  she  wanted  to  say  something  to  her,  but  only 
stared  and  said  nothing. 

Four  days  before  admission  she  became  quite  immobile,  lay  in 
bed,  did  not  speak,  eat  or  drink.     She  also  had  some  fever. 

The  patient  herself,  when  well,  described  the  onset  of  her 
psychosis  as  follows:  She  knew  of  no  cause  except  that  her 
brother,  some  time  before  the  onset  (not  clear  how  long),  was 
run  over  by  an  automobile  and  had  his  foot  hurt.  She  claimed 
that  while  still  working  she  lost  her  ambition,  lost  her  appetite, 
did  not  feel  like  talking  to  any  one;  that  when  she  went  out  with 
her  mother  it  merely  seemed  to  her  that  people  stared  at  her. 
The  day  before  she  went  to  the  Observation  Pavilion  her  cousin 
came  to  see  her,  and  she  thought  she  saw,  standing  beside  this 
cousin,  the  latter's  dead  mother.  She  also  thought  there  was  a 
fire,  and  that  her  sister  was  sweeping  little  babies  out  of  the 
room.  Then,  she  claimed,  she  felt  afraid  (this  still  on  the  day 
before  going  to  the  Observation  Pavilion)  because  she  had  re- 
peated visions  of  an  old  woman,  a  witch.  This  woman  said,  "I 
am  your  mother,  and  I  gave  you  to  this  woman  (i.  e.,  patient's 
real  mother)  when  you  were  a  baby."  She  also  was  afraid  her 
mother  was  "going  away," 

At  the  Observation  Pavilion  she  was  described  as  constrained, 
staring  fixedly  into  space,  mute,  requiring  to  be  dressed  and  fed. 


8  BENIGN  STUPORS 

Under  Observation:  1.  For  five  months  the  patient  pre- 
sented a  marked  stupor.  She  was  for  the  most  part  very  inac- 
tive, totally  mute,  staring  vacantly,  often  not  even  blinking,  so 
that  for  a  time  the  conjunctivee  were  dry.  She  did  not  swallow, 
but  held  her  saliva;  did  not  react  to  pin  pricks  or  feinting 
motions  before  her  eyes.  Sometimes  she  retained  her  urine, 
again  wet  and  soiled  the  bed.  Often  there  was  marked  cata- 
lepsy, and  the  retention  of  very  awkward  positions.  As  a  rule 
she  was  quite  stiff,  offering  passive  resistance  towards  any  in- 
terference. She  had  to  be  tube-fed  at  first.  Later  she  was 
spoon-fed,  and  then  would  swallow,  in  spite  of  the  fact  that  dur- 
ing the  interval  between  her  feeding  she  would  let  saliva  col- 
lect in  her  mouth.  For  a  time  she  had  a  tendency  to  hold  one 
leg  out  of  bed,  and  when  it  was  put  back  would  stick  the  other 
out.  Sometimes  she  walked  of  her  own  accord  to  the  toilet  chair, 
but  on  one  occasion  wet  the  floor  before  she  got  there. 

During  the  first  month  after  admission,  this  stupor  was  inter- 
rupted for  two  short  periods  by  a  little  freer  action:  she  walked 
to  a  chair,  sat  down,  smiled  a"  little,  fanned  herself  very  natu- 
rally when  a  fan  was  given  to  her,  though  even  then  did  not 
speak. 

There  was,  as  a  rule,  no  emotional  reaction,  but  after  some 
months  she  several  times  wept  when  her  mother  came,  though 
without  speaking.     Once  when  taken  to  the  tub  she  yelled. 

Her  physical  condition  during  this  stupor  was  as  follows :  She 
menstruated  freely  on  admission,  then  not  again  until  she  was 
well.  Several  times  she  had  rises  of  temperature  to  102°  or  103° 
with  a  high  pulse  and  respiration;  again  a  respiration  of  40, 
with  but  slight  rise  of  temperature,  though  the  pulse  had  a  ten- 
dency to  go  to  130  and  over.  She  was  apt  to  show  marked  skin 
hypersemia  wherever  touched.  With  the  fever  there  was  found 
a  leucocytosis  of  from  11,900  to  15,000,  with  marked  increase  of 
polynuclear  leucocytes  (89%).  She  got  very  emaciated,  so  that 
four  months  after  admission  she  weighed  68  lbs.  (height  5'  2"). 

2.  About  five  months  after  admission  she  was  often  seen  smil- 
ing, and  again  weeping,  and  she  began  to  talk  a  little  to  the 
nurses,  though  not  to  the  doctors.  She  also  began  to  eat  exces- 
sively of  her  own  accord,  and  rapidly  gained  weight,  so  that 


TYPICAL   CASES  OF  DEEP   STUPOR  9 

by   January  she  weighed  981/2   lbs.,   a  gain   of  30   lbs.  in   two 
months.     Yet  she  continued  to  be  sluggish. 

3.  For  two  more  months  she  was  apathetic  and  appeared  dis- 
interested, often  would  not  reply,  again,  at  the  same  interview, 
she  would  do  so  promptly  and  with  natural  voice.  This  condi- 
tion may  be  illustrated  by  the  summary  of  a  note  made  on  Janu- 
ary 29,  1908,  which  is  representative  of  that  period.  It  is  stated 
that  she  sat  abo'ut  apathetically  all  day,  appeared  sluggish,  but 
was  fairly  neat  about  her  appearance  and  cleanly  in  her  habits. 
There  was  at  no  time  any  evidence  of  affect,  except  when  asked 
by  the  examiner  to  put  out  her  tongue  so  that  he  could  stick  a  pin 
in  it  she  blushed  and  hid  her  face.  When  asked  whether  she 
worried  about  anything,  she  denied  this.  When  questions  were 
asked,  she  sometimes  answered  promptly  and  in  normal  voice, 
again  simply  remained  silent  in  spite  of  repeated  urging.  On 
the  whole,  it  seemed  that  simple  impersonal  questions  were  an- 
swered promptly;  whereas  difficult  impersonal  questions  or  ques- 
tions which  referred  to  her  condition  were  not  answered  at  all. 
She  proved  to  be  oriented.  Thus  she  gave  the  day  of  the  week, 
month,  year,  the  name  of  the  hospital,  names  of  the  doctors  and 
nurses  promptly.  She  also  counted  quickly  and  did  a  few  sim- 
ple multiplications  quickly.  But  she  was  silent  when  asked 
where  the  hospital  was  located,  how  long  she  had  been  here, 
whether  she  was  here  one  or  six  months,  how  she  felt.  Ques- 
tions in  regard  to  the  condition  she  had  passed  through,  or  in- 
volving difficult  calculations,  she  did  not  answer.  However, 
some  questions  regarding  her  condition  asked  in  such  a  way  that 
they  could  be  answered  by  "yes"  or  "no"  were  again  answered 
quite  promptly.  Thus  when  asked  whether  her  head  felt  all 
right  she  said,  "Yes,  sir."  (Is  your  memory  good?)  "Yes." 
(Have  you  been  sick?)     "No,  sir."     (Are  you  worried?)     "No." 

4.  This  apathy  cleared  up  too,  so  that  by  the  middle  of  March 
she  was  bright,  active  and  smiled  freely.  With  the  nurses  she 
was  rather  talkative  and  pleased,  though  this  was  not  marked. 
Towards  the  physician  only  was  she  natural  and  free.  She  then 
gave  the  retrospective  account  of  the  onset  detailed  above.  When 
questioned  about  her  condition  she  claimed  not  to  remember  the 
Observation  Pavilion,  although  recalling  vaguely  going  there  in 
a  carriage.     She  was  almost  completely  amnesic  for  a  consider- 


10  BENIGN  STUPORS 

able  part  of  her  stay  in  the  Institute.  She  claimed  it  was  only 
in  November  or  December  that  she  began  to  know  where  she  was 
(five  months  after  admission).  In  harmony  with  this  is  the  fact 
that  she  did  not  recall  the  tube-  and  spoon-feeding  which  had 
to  be  resorted  to  for  about  four  months  of  this  period.  No 
ideas  or  visions  were  remembered.  As  to  her  mutism  she  said, 
"I  don't  think  I  could  speak,"  "I  made  no  effort,"  again  "I  did 
not  care  to  speak."  She  claimed  that  she  remembered  being 
pricked  with  a  pin  but  that  she  did  not  feel  it.  She  remem- 
bered yelling  when  taken  to  the  tub  (towards  end  of  the  marked 
stupor)  and  claimed  she  thought  she  was  to  be  drowned. 

When  she  went  home  (March  24,  1908)  she  got  into  a  more 
elated  condition.  She  was  talkative,  conversed  with  strangers 
on  the  street,  said  to  her  mother  that  she  was  now  sixteen  years 
old  and  wanted  "a  fellow."  When  the  mother  would  not  allow 
her  to  go  out,  she  said  it  would  be  better  if  they  both  would  j  ump 
out  of  the  window  and  kill  themselves.  She  then  was  sent  back 
to  the  hospital.  In  the  first  part  of  this  period  after  her  return, 
she  was  somewhat  elated  and  overtalkative,  though  she  did  not 
present  a  flight  of  ideas,  and  was  well  behaved.  She  soon  got 
well,  however,  and  was  discharged,  four  months  after  her  read- 
mission,  fully  recovered. 

After  that,  it  is  claimed,  she  was  perfectly  well  and  worked 
successfully  most  of  the  time  with  the  exception  of  a  short  period 
in  the  spring  of  1909,  when  she  was  slightly  elated. 

In  1910  she  had  a  subsequent  attack,  during  which  she  was 
treated  at  another  hospital.  Fl-om  the  description  this  again 
seems  to  have  been  a  typical  stupor  (immobility,  mutism,  ten- 
dency to  catalepsy,  rigidity).  According  to  the  account  of  the 
onset  sent  by  that  hospital  (it  was  obtained  from  the  mother), 
this  attack  began  some  months  before  admission,  with  complaints 
of  being  out  of  sorts,  not  being  able  to  concentrate  and  fearing 
that  another  attack  would  come  on.  Finally  the  stupor  was  said 
to  have  been  immediately  preceded  by  a  seizure  in  which  the 
whole  body  jerked.     She  made  again  an  excellent  recovery. 

The  patient  was  seen  about  two  years  after  this  attack,  and 
described  the  development  of  the  psychosis  as  follows:  She 
claimed  she  began  to  feel  "queer,"  "nervous,"  "depressed,"  got 
sleepless.     Then    (this  was   given   spontaneously)    she  suddenly 


TYPICAL   CASES  OF  DEEP   STUPOR  11 

thought  she  was  dying  and  that  her  father's  picture  was  talking 
to  her  and  calling  her.  "Then  I  lost  my  speech."  As  after  the 
first  attack,  she  claimed  not  to  have  any  recollection  of  what  went 
on  during  a  considerable  part  of  the  stupor  but  recalled  that 
she  began  to  talk  after  her  brother  visited  her.  It  is  not  clear 
how  she  was  during  the  period  immediately  following  the  stupor. 
She  made  a  very  natural  impression  and  came  willingly  to 
the  hospital  in  response  to  a  letter  and  was  quite  open  about  giv- 
ing information. 

Case  2. — Caroline  DeS.  Age:  21.  Admitted  to  the  Psychi- 
atric Institute  June  10,  1909. 

F.  H.  The  father  died  of  apoplexy  when  patient  was  nine. 
The  mother  had  diabetes.     A  paternal  uncle  was  queer,  visionary. 

P.  H.  The  patient  was  always  considered  natural,  bright,  had 
many  friends,  and  was  efficient. 

Some  months  before  admission  the  patient's  favorite  brother, 
who  is  a  Catholic,  became  engaged  to  a  Protestant  girl,  and 
spoke  of  changing  his  religion.  The  family  and  the  patient  were 
annoyed  at  this,  and  the  patient  is  said  to  have  worried  about 
it,  but  was  otherwise  quite  natural  until  seven  days  before  ad- 
mission. Then,  at  the  engagement  dinner  of  the  brother,  the 
psychosis  broke  out.  She  refused  to  sit  down  to  the  table,  and 
then  suddenly  began  to  sing  and  dance,  cry  and  laugh  and  talk 
in  a  disconnected  manner.  Among  other  things,  she  said  "I 
hate  her,"  "I  love  you,  papa"  (father  is  dead),  "Don't  kill  me." 
She  struck  her  brother.  She  was  in  a  few  days  taken  to  the 
Observation  Pavilion. 

The  patient  stated  after  recovery  that  what  worried  her  was 
that  the  brother  would  marry  a  Protestant  and  that  he  would 
leave  home  (favorite  brother). 

At  the  Observation  Pavilion  she  was  excited,  shouted,  screamed, 
laughed,  called  out  "Don't  kill  me,"  again  "Brother,  brother," 
"You  are  my  brother"  (to  doctor). 

Under  Observation,  1.  On  admission,  and  for  two  weeks,  the 
patient  presented  a  marked  excitement,  during  most  of  which 
she  was  treated  in  the  continuous  bath.  She  tossed  about,  threw 
the  sheets  off,  beat  her  breasts  and  abdomen,  put  her  fingers 
into  her  mouth,  bit  the  back  of  her  hands,  waved  her  arms  about, 


12  BENIGN  STUPORS 

sometimes  with  peculiar  gyration,  etc.,  at  the  same  time  shouting, 
singing,  again  praying,  laughing  or  crying,  sometimes  fighting 
the  nurses  and  resisting  them.  She  also  talked  quite  a  little  as 
a  rule,  but  there  were  periods  when,  although  excited,  she  would 
not  talk  or  answer  questions.  She  was  very  little  influenced  in 
her  talk  by  the  environment.  When  on  one  occasion  asked  if  she 
had  any  trouble,  she  said:  "No — I  don't  want,  somebody  else 
gave  me  a  book — all  right  I  love  myself.  Uncle  Mike  too — all 
right  too — all  right  I  am  in  Bellevue — I  love  everybody  except 
the  Jews  all  right,  all  right — give  me  water,  give  me  milk,  give 
me  seltzer — white  horse  uncle — Holy  Father,  he  is  killing  me, 
I  want  my  mother,"  or  "Wait  a  minute,  say,  that's  a  lie — oh  no, 
Holy  water — no  I  didn't  wash  the  water  away — oh,  she  forgets, 
I  am  sick — ^mother  why  don't  you  come — look  at  the  baby,  they 
knocked  my  head  against  the  wall — ^wait  a  minute,  isn't  that  ter- 
rible?— I  was  married — I  was  so — I  forgot — April  fool — I  kiss 
you  seven  kisses  and  one  more — I  love  papa  and  mamma,  I  like 
others  too — I  am  papa's  angel  child — yes  I  confess  I  love  him, 
but  I  don't  want  to  die  myself."  On  another  occasion,  when 
asked  where  she  was,  she  said:  "I  am  at  the  ball — I  am  going 
to  Heaven — don't  shoot  me"  (affectless).  (Why  are  you  afraid?) 
"Because  you  see — high  water  (in  the  tub) — white  horse." 
(What  about  the  water?)  "My  name  is  Caroline — if  you  love 
me,  father,  tickle  me  under  my  feet,"  or,  rolling  her  eyes  up, 
"Oh,  isn't  that  awful,  that  ring,  that  diamond,  that  is  the  key 
to  Heaven." 

2.  For  about  ten  days  she  was  somewhat  different.  She  be- 
came quieter  and  at  first  lay  muttering  unintelligibly,  saying 
some  things  about  being  killed,  but  speaking  little,  often  restlessly 
tossing  about  and  tremulous.  She  had  to  be  tube-fed.  On  one 
day  (July  1)  she  smiled  more  and  talked  more,  said  to  the 
physician  "You  have  been  arrested  for  me — ^you  arrested  the 
first  man  that  I  ever — New  York  State — let  me  see  that  book" 
(note  pad).  Then  she  went  on:  "Oh,  I  am  all  apart — diamonds 
— they  didn't  know — ^must  I  keep  them  clean? — ^what  is  your 
name? — that  is  another  thing  I  would  like  to  know."  But  when 
asked  what  house  she  was  in  she  said :  "This  is  the  same  Ward's 
Island"  and  then  added,  "How  long  have  I  been  here? — ^there  is 
my  picture  up  there  (register),  who  is  that?  (listening)  it's  Ida 


TYPICAL   CASES  OF  DEEP   STUPOR  13 

..."  She  began  to  sing  softly.  Then  again  she  whined. 
"0  mamma,  mamma!"  When  asked  how  long  she  had  been 
here,  she  said:  "Since  Decoration  Day,  when  my  father  went 
in  my  sister's  house,  nobody  could  catch  up  with  me — somebody 
blackened  her  eyes."  When  asked  whether  she  was  sick,  she 
said  "No,  insane." 

Although,  as  was  stated,  she  said  at  one  time,  "This  is  the 
same  Ward's  Island,"  usually  questions  regarding  orientation 
were  not  answered,  as  she  gave  few  relevant  replies,  but  she  re- 
peatedly said  spontaneously  that  she  was  in  "Hoboken  or  Belle- 
vue,"  and  called  the  nurse  by  the  name  of  a  former  teacher.  A 
few  days  after  this  state  had  developed  she  had  a  fever.  Once 
this  rose  to  104°.  The  fever  lasted  two  weeks,  coming  down 
gradually.  It  was  associated  with  a  leucocytosis  of  15,000  on 
June  29  (no  differential  count)  and  with  coated  tongue.  No 
Widal    (two   examinations).     No  diazo    (July  1). 

3.  Then  while  the  temperature  still  lasted  she  developed  a 
stupor  which  persisted  for  about  a  year.  During  this  time  her 
temperature  rose  to  100°  without  ascertainable  cause.  She  lay 
for  the  most  part  motionless,  changing  her  position  but  rarely; 
her  expression  was  stolid;  she  retained  and  drooled  saliva,  wet 
and  soiled  herself.  She  never  answered  any  questions;  showed 
no  interest  whatever.  At  times  she  was  quite  stiff  and  very  re- 
sistive but  never  cataleptic.  Her  extremities  were  cold  and  cya- 
notic. She  had  to  be  tube-fed  throughout.  During  this  time 
she  lost  much  hair. 

After  some  months  she  occasionally  gazed  about  furtively,  or 
later  watched  everything  when  unaware  of  being  observed;  at 
this  time  she  also  smiled  occasionally  at  amusing  things,  or  per- 
haps said  "yes"  or  "no"  to  questions,  but  usually  was  stolid  when 
interrogated. 

Then  about  nine  months  after  admission,  while  in  the  coijdi- 
tion  just  described,  she  developed  a  lobar  pneumonia.  During 
it  she  remained  the  same.  But  during  convalescence  she  began 
to  speak  and  eat. 

4.  A  period  followed  lasting  six  months  during  which  she  was 
up  and  about,  but  sat  or  stood  around  a  good  deal.  On  the 
other  hand,  she  helped  the  nurses  a  little  when  urged.  Her 
face  was  often  stolid,  again  she  looked  about.    At  times   (even 


14  BENIGN  STUPORS 

nearly  to  the  end)  she  drooled  and  soiled.  She  said  little.  At  no 
time  was  she  resistive.  On  other  occasions  she  smiled  or  laughed, 
not  always  on  provocation,  or  she  showed  little  playful  tendencies, 
such  as  throwing  a  pillow  about  the  room,  tearing  leaves  from  the 
plants,  taking  the  doctor's  arm  and  walking  down  the  hall,  ask- 
ing him  to  kiss  her.  At  such  times  she  often  looked  quite  bright, 
keen,  alert  and  amused.  Towards  the  end  she  would  give  at 
times  playful  answers,  such  as  "I  came  to-day,"  or  "This  is  the 
Hall  of  Fame."  This  tapered  off,  so  that  by  December,  1910, 
she  was  perfectly  well. 

Betrospectively,  the  patient  claimed  not  to  remember  the  up- 
set at  the  dinner,  or  what  happened  afterward,  although  recall- 
ing the  trip  to  the  Observation  Pavilion.  She  denied  any 
memory  of  the  journey  to  the  hospital,  but  could  tell  what  ward 
she  came  to.  How  well  the  condition  after  that  was  recalled, 
was  not  inquired  into,  except  that  she  could  or  would  not  explain 
further  the  utterances  during  the  first  period.  For  the  stupor 
period  it  is  stated  that  she  remembered  many  external  facts,  but 
it  is  not  clear  in  which  period  they  occurred. 

Catamnestic  Note.  May,  1913 :  She  has  worked  efficiently,  and 
is  said  to  have  been  perfectly  well. 

Case  3. — Mary  F.  Age:  21.  Admitted  to  the  Psychiatric 
Institute  June  28,  1902. 

F.  H.  The  mother  died  when  the  patient  was  five.  The  father 
was  living,  an  alcoholic  and  reckless  man.  Four  brothers  and 
sisters  died  in  infancy. 

P.  H.  The  patient  was  the  only  surviving  child.  She  was 
brought  up  in  a  convent  and  orphan  asylum  until  11,  when 
her  father  remarried.  At  12  she  had  to  go  to  work,  hence  she 
had  but  little  education.  She  was  bright,  efficient,  well  liked 
by  her  employers  (in  one  position  five  years).  As  to  her  pe- 
culiarities, she  was  thought  to  be,  perhaps,  a  little  headstrong, 
and  was  also  described  as  always  very  exact,  rather  quick-tem- 
pered and  inclined  to  be  irritable  when  crossed. 

She  was  married  six  months  before  admission  and  had  a  haly 
three  weeks  before  admission.  The  husband  stated  that  whtn 
the  father  found  out  she  was  pregnant,  he  spoke  of  killing  him. 
He  frequently  upbraided  both  husband  and  wife,  though  he  lived 


TYPICAL   CASES  OF  DEEP  STUPOR  15 

with  them.  Even  after  the  child  was  born  he  continued  to  be 
disagreeable. 

The  patient  was  rather  low  spirited  and  quieter  after  her  mar- 
riage. She  worried  over  her  illegitimate  pregnancy  and  the  scold- 
ing from  her  father.  But  nothing  was  thought  of  all  this,  and 
it  did  not  interfere  with  her  activity.  The  birth  was  normal. 
She  had  no  flow,  no  unfavorable  symptoms,  and  sat  up  on  the 
twelfth  day.     She  is  said  to  have  appeared  natural  mentally. 

A  week  before  admission  the  family  returned  from  the  christ- 
ening, having  left  the  patient  apparently  well.  They  now  found 
her  sitting  in  her  chair,  limp,  with  closed  eyes,  giving  no  answer 
to  questions.  Only  after  about  twenty  minutes  could  she  hi 
aroused.  After  her  father  had  given  her  milk  with  whiskey  in 
it,  she  claimed  he  had  poisoned  her.  In  the  evening  she  wa?i 
bright  and  lively,  singing  and  dancing  with  the  others,  but  in 
the  night  she  woke  up  her  husband,  seemed  frightened,  said 
somebody  was  in  the  room  and  that  he  should  get  a  priest  as  she 
was  going  to  die.  The  husband  went  to  sleep  again.  The  next 
forenoon  the  patient  claimed  she  had  been  frightened  all  night 
and  thought  her  father  was  going  to  kill  her  husband. 

On  the  second  day,  while  sitting  at  breakfast,  she  groped  about 
for  the  bread  plate  for  some  time  and  then  said  she  had  been 
blind  for  a  short  time.  During  the  day  she  had  frequent  spells 
in  which  she  would  close  her  eyes,  become  perfectly  quiet  and 
difficult  to  rouse.  Sometimes  at  the  beginning  of  these  spells 
she  would  say  "I  am  going."  She  was  then  taken  to  her  aunt 
and  walked  there,  a  distance  of  a  few  blocks.  She  was  there  for 
two  days  before  going  to  the  Observation  Pavilion.  In  this  time 
she  is  said  to  have  been  quiet  for  the  most  part,  often  appar- 
ently sleeping  or  staring.  Once  she  said  she  was  "rather  dirty, 
filthy."  Once  she  tried  to  get  out  of  the  window,  said  it  was  a 
door  and  that  she  wanted  to  get  out  and  take  a  walk.  Above 
all,  she  had,  in  these  two  days,  repeated  peculiar  seizures  which 
the  aunt  and  the  husband  described  as  follows:  When  sitting 
on  a  chair  she  would  close  her  eyes,  clench  her  fists,  pound  the 
side  of  the  chair,  get  stiff,  slide  on  the  floor,  then  thrash  her 
arms  and  legs  about  and  move  the  head  to  and  fro.  She  frothed 
at  the  mouth.  After  the  attack,  which  lasted  a  few  minutes,  she 
breathed   heavily   for   a  while.     Once  she   wiped   off   the   froth 


16  BENIGN  STUPOES 

with  a  handkerchief  and  gave  the  latter  to  the  aunt,  saying 
"Burn  that,  it  is  poison."  Before  the  attack  she  sometimes  said 
that  it  got  dark  over  her  eyes  and  that  her  face  felt  funny,  again 
that  she  had  a  pain  in  the  stomach  which  worked  towards  her 
right  shoulder.  There  was  no  cry  in  the  beginning  of  the  attack, 
but  once  she  wet  herself. 

After  recovery  the  patient  herself  told  the  development  of  her 
psychosis  thus: 

There  was  trouble  between  the  father  and  the  husband,  and 
she  was  afraid  of  her  father.  On  the  day  of  the  christening  she 
took  sick:  a  queer  feeling  came  over  her  and  she  wondered 
whether  she  was  going  to  die,  "Then  I  seemed  to  lose  myself,  and 
when  I  came  to  I  found  my  family  standing  around  me."  Pier 
father  gave  her  whiskey  and  she  thought  it  was  poison.  "That 
night  I  had  spells  of  dancing  and  singing,  it  must  have  been 
something  I  took,  perhaps  the  liquor."  The  same  night  she  was 
frightened,  thought  her  father  might  do  some  harm,  and  had  a 
vision  of  a  person  in  white  standing  at  her  bed.  After  that  she 
had  repeated  spells  in  which  she  knew  nothing  until  "I  came  to 
again."     "It  was  a  queer  trembling." 

At  the  Observation  Pavilion  she  was  described  as  in  a  state  of 
"intense  mental  depression,"  taking  no  interest  in  things  going 
on  about  her.  She  spoke,  however;  said  she  wanted  to  die,  that 
she  had  imagined  her  father  had  given  her  poison,  that  every 
one  was  against  her,  and  that  people  were  talking  about  her. 

1.  On  admission  the  patient  had  a  slightly  elevated  tempera- 
ture, which  soon  subsided,  full  breasts  but  without  inflammation. 
Sordes  were  not  mentioned. 

For  a  few  days  she  was  essentially  somewhat  restless,  getting 
out  of  bed,  disarranging  her  clothes,  wandering  about — all  in  a 
rather  deliberate,  aimless  way,  sometimes  vaguely  resistive,  again 
with  free  movements.  She  looked  dazed,  sometimes  stared 
straight  ahead  and  looked  "dreamy."  Occasionally  there  was  a 
tendency  to  close  her  eyes.  With  the  restlessness  she  looked  at 
times  "a  little  apprehensive,"  or  shrank  away  when  approached. 
She  spoke  slowly,  with  initial  difficulty,  but  answered  quite  a 
number  of  questions.  The  mental  content  of  this  period  was 
displayed  in  the  following  utterances :  She  would  ask  for  a 
priest,  or  say  "Have  I  done  something?"  or  "Do  people  want 


TYPICAL   CASES  OF  DEEP   STUPOR  17 

something'?"  or,  when  asked  why  she  was  here,  she  said  "I  have 
done  damage  to  the  city,  didn't  I?"  (What  have  you  done?) 
"I  don't  know."  Or  she  spoke  of  people  watching  her.  When 
asked  the  day,  she  said  "Judgment  Day,"  yet  she  knew  the  month. 
Once  when  asked  what  the  place  was  she  said,  "This  is  the  here- 
after." When  asked  what  had  happened  at  home,  she  said: 
"Voices  told  me  I  was  to  be  killed."  She  was  not  clearly  oriented, 
called  the  place  Bellevue,  asked  "Isn't  this  a  hospital"?"  yet  again 
said,  "Ward's  Island,  where  they  work."  On  the  day  of  admission 
she  thought  she  came  "the  day  before,"  but  knew  she  had  come 
in  a  boat.  When  asked  her  address,  she  said  slowly,  "Didn't  I 
live  at,  etc.,"  giving  the  address  correctly.  To  the  physician  she 
said,  "Are  you  my  brother?"  And  on  another  occasion,  "My 
God!  You  are  Charlie"  (brother).  It  was  difficult  to  get  her 
to  eat,  and  she  had  to  be  spoon-fed. 

2.  Then  she  became  more  preoccupied,  the  restlessness  was 
much  less  in  evidence,  it  became  necessary  to  tube-feed  her,  she 
retained  her  urine,  answered  a  few  questions,  and  when  asked  where 
she  was,  she  said,  "Calvary,  ain't  it?"  (What  house?)  "Heaven, 
ain't  it?"  She  still  called  the  physician  by  the  name  of  her 
brother.  After  a  few  days  this  gave  way  to  a  more  marked 
stupor  which  lasted  nearly  two  years.  This  was  characterized 
most  frequently  by  a  complete  inactivity.  She  usually  lay  or 
sat  motionless,  sometimes  with  mouth  partly  open,  letting  the  flies 
crawl  over  her  face,  gazing  in  one  direction,  soiling,  wetting, 
resisting  moderately  or  markedly  any  interference,  and  had  to  be 
tube-fed.  But  this  was  not  the  invariable  state.  The  most 
constant  feature  was  her  mutism,  but  even  that  was  a  few  times 
interrupted.  Thus,  when  after  a  visit  from  her  uncle  (towards 
the  end  of  July,  1902)  she  tried  to  get  out  of  the  window  and 
was  prevented,  she  swore  at  the  nurse.  Or  in  August,  1902, 
when  she  got  into  another  patient's  bed  and  was  taken  out,  she 
resisted  and  said  promptly:  "I  think  it  is  a  damned  shame  I 
can't  get  into  my  own  bed."  But  this  was  the  extent  of  her  talk 
for  a  year  and  a  half.  Nor  was  she  always  totally  inactive.  In 
the  middle  of  July,  1902,  she  sometimes  tried  to  get  out  of  bed, 
wandered  about,  got  into  other  patients'  beds.  It  was  on  such 
an  occasion  that  the  above  incident  happened.  In  August,  1902, 
she  sometimes  tried  to  get  out  when  the  door  was  opened,  and 


18  BENIGN  STUPORS 

we  have  seen  that  she  tried  to  get  out  of  the  window,  but  she  did 
not  change  her  placid  expression  at  such  times.  Her  motive  was 
not  known.  On  two  occasions  towards  the  end  of  1902,  when 
she  was  taken  to  a  dance  and  was  made  to  take  part,  she  waltzed 
with  considerable  animation  but  did  not  speak.  This  was  quite 
striking  in  that  these  incidents  occurred  in  a  setting  of  marked 
inactivity  (i.  e.,  a  condition  in  which  she  had  to  be  pushed  to  the 
table,  pushed  to  the  closet).  She  did  not  soil  any  more,  but 
she  sometimes  drooled  and  had  to  be  spoon-fed.  However,  on  a 
third  occasion  when  this  was  tried,  she  had  to  be  dragged  around. 
Finally,  though  her  facial  expression  showed  at  times  a  preoc- 
cupied staring,  she  more  often  looked  around,  sometimes  quite 
freely  and  often  looked  up  promptly  enough  when  accosted.  But 
there  was  very  little  evidence  of  any  affect  at  any  time.  We  have 
seen  that  twice  she  swore  a  little  when  opposed.  On  another 
occasion  she  slapped  a  patient  when  the  latter  helped  her.  Twice 
she  was  seen  crying  a  little  without  apparent  provocation,  but 
she  did  not  laugh,  and  the  only  suggestion  of  pleasurable  emotion 
was  that  at  the  two  dances  mentioned  she  could  be  led  into  a 
certain  animation.  Usually,  even  when  she  got  less  resistive 
towards  the  end,  she  was  essentially  apathetic. 

Once  in  January,  1903,  she  could  be  made  to  write  her  name 
but  wrote  her  maiden  name.  In  the  end  of  1903  she  improved 
gradually  (a  condition  not  well  observed),  so  that  by  December 
she  answered  some  questions  in  a  low  tone.  Even  in  April,  1904, 
she  was  still  described  as  apathetic,  though  she  had  begun  to  do 
some  work. 

3.  Then  she  improved  markedly  and  began  to  work,  looked 
after  herself  in  a  natural  way,  spoke  freely,  was  entirely  oriented 
and  her  mood  generally  presented  nothing  striking.  But  her 
mental  attitude  was  still  peculiar  when  she  was  questioned.  She 
seemed  somewhat  inattentive,  sulky,  sneering.  Thus,  when  asked 
why  she  was  here,  she  said,  "You  will  have  to  ask  those  who 
brought  me  here." 

She  denied  ever  having  been  pregnant,  said  the  nurses  on  the 
ward  had  spoken  of  her  having  had  a  child  and  that  they  had 
showed  her  a  child  (one  was  born  on  that  ward  about  August, 
1903)  but  that  it  was  not  hers.  She  thought  it  was  wrong  for 
the  nurses  to  speak  on  the  ward  of  her  having  been  pregnant. 


TYPICAL  CASES  OF  DEEP  STUPOR  19 

Again  questioned  about  her  marriage,  she  first  said  she  had  not 
been  married,  again  that  she  was  married  "a  year  ago"  (was  in 
the  hospital  then).  Again  she  spoke  of  her  husband  as  her 
"gentleman  friend/'  claimed  she  called  herself  Mary  M.  (maiden 
name)  until  a  girl  friend  wrote  her  a  letter  addressed  to  Mrs.  F. 
From  then  on,  she  called  herself  by  her  married  name.  But  she 
thought  that  probably  they  sometimes  spoke  of  her  marriage  in 
fun.    If  she  were  Mrs.  F.  she  would  be  living  in  Mr.  F.'s  house. 

On  June  29,  when  again  asked  about  her  marriage,  she  said 
she  was  to  have  been  married  in  December  (correct  date).  (Were 
you?)  "So  they  say."  (Do  you  remember  it?)  "In  a  way." 
(When  was  the  baby  born?)  "You  will  have  to  ask  somebody 
more  superior  to  me,  more  experienced."  Then,  when  further 
questioned  about  the  age  of  the  baby,  she  said,  "The  baby  I  saw 
in  the  ward  was  about  a  year  old,"  and  she  claimed  not  to 
remember  ever  having  a  baby.  When  asked  why  she  had  come 
here  she  said,  "Well,  I  don't  know,  perhaps  you  know  better, 
through  sickness  I  guess,"  and  later:  "Well,  don't  you  ever  get 
a  cold  and  want  doctors  to  examine  you?"  (What  kind  of  a 
place?)  "This  is  a  nice  place  for  sensible  people  who  have 
enough  knowledge  to  know  and  realize  what  they  come  for."  But 
she  knew  the  name  of  the  place,  the  date,  the  names  of  persons. 

Questioned  about  the  trouble  with  her  father  or  her  husband's 
trouble  with  him,  she  denied  it,  "If  he  did  (sc.  have  any  trouble), 
I  don't  remember."  About  her  not  speaking,  she  said,  in  answer 
to  questions,  "I  didn't  know  what  I  was  here  for,  what  was  the 
object  in  keeping  me  here";  and  to  other  questions  about  her 
condition,  "I  don't  know,  those  who  examined  me  can  tell  you 
more  about  that."  Finally,  she  said  in  reply  to  the  question, 
why  she  came  here,  "I  don't  remember  unless  it  was  through  fire/' 
but  would  not  explain  what  she  meant. 

In  the  beginning  of  July,  she  again  said  that  she  had  no  recol- 
lection of  her  marriage. 

She  then  improved  a  great  deal  and  finally  appeared  very 
natural,  gave  the  retrospective  account  noted  in  the  history,  had 
a  clear  appreciation  of  the  fact  that  she  was  married  and  had  a 
child.  She  claimed  that  she  had  previously  forgotten  about  her 
marriage  and  thought  she  was  still  merely  keeping  company  with 
Mr.  F.     She  claimed  not  to  remember  coming  to  the  hospital, 


20  BENIGN  STUPOKS 

did  not  know  what  ward  she  came  to,  who  the  doctor  and  nurses 
were,  in  fact  claimed  that  it  was  about  a  year  before  she  knew 
vvhere  she  was.  But  she  remembered  having  been  tube-fed.  She 
could  not  say  why  she  did  not  speak.  But  she  appreciated  that 
she  had  been  ill. 

Ten  years  after  discharge  the  husband,  in  answer  to  an  inquiry, 
stated  that  she  had  been  perfectly  well  and  had  had  no  trouble 
at  three  successive  childbirths. 

Case  4. — Mary  D.  Age:  20.  Admitted  to  the  Psychiatric 
Institute  September  17,  1907. 

F.  H.  The  grandfather  and  the  father  of  the  patient  were 
alcoholics.  The  father  died  three  years  before  the  patient's 
admission;  he  was  killed  in  an  accident.  The  mother  stated  that 
she  herself  was  nervous,  but  she  made  a  normal  impression. 

P.  H.  The  patient  was  described  as  bright  at  school  and 
efficient  in  her  work  as  a  dressmaker,  but  she  was  rather  quiet, 
inclined  to  stay  at  home  and  had  not  much  inclination  to  consort 
with  the  other  sex.  She  was  rather  proud.  As  an  example  of 
this  is  stated  the  fact  that  she  was  always  somewhat  sensitive, 
because  the  family  lived  in  the  basement  of  the  house  in  which 
her  mother  was  janitress.  She  did  not  menstruate  until  16.  It 
was  about  this  time  that  her  father  was  killed  in  an  accident. 
She  was  considerably  upset  by  this,  talked  a  good  deal  about  the 
way  he  was  killed,  but  did  not  break  down.  The  patient  on 
recovery  stated  that  it  worried  her  because  the  father  died  without 
having  any  chance  to  get  a  priest. 

Six  weeks  before  admission  the  patient  was  given  a  vacation, 
as  there  was  not  work  enough  in  the  shop,  but  she  worked  at 
home. 

Two  or  three  weeks  before  admission  her  appetite  failed  some- 
what, and  ten  days  before  admission,  without  any  appreciable 
cause,  she  began  to  sleep  badly,  seemed  somewhat  nervous,  became 
a  little  "fidgety"  and  said  she  worried  because  her  mother  had  to 
work  so  hard.  Later  she  began  to  speak  about  people  saying  that 
the  ambulance  would  come  for  her  and  she  heard  voices  saying 
"You  will  be  dead."  It  is  not  known  in  what  emotional  setting 
these  remarks  were  made.  Her  mother  took  her  to  a  dispensary. 
On  the  way  she  asked  the  mother  where  she  was  going  and  said 


TYPICAL   CASES  OF  DEEP  STUPOR  21 

"I  can't  tell  the  number  and  I  don't  know  where  I  am  going.  I 
think  I  am  losing  my  mind."  She  also  said  she  could  not  under- 
stand any  more  what  she  read.  She  was  put  to  bed.  She  then 
talked  less,  appeared  stupid,  and  was  inclined  to  refuse  food. 

Four  days  before  admission  she  claimed  that  she  could  see  her 
dead  father  beckoning  to  her,  again  she  said  a  certain  young  man 
was  God.  She  was  sent  to  the  Observation  Pavilion.  On  the 
day  she  went  there  she  was  reported  to  have  shown  a  slight 
jaundice. 

The  patient,  after  her  recovery,  added  to  the  above  account  of 
the  mother,  that  about  two  weeks  before  admission,  for  no  reason 
which  she  could  state,  she  began  to  feel  quiet,  and  that  after  that 
her  father's  death  began  to  prey  on  her  mind,  and  that  later  she 
had  a  vision  of  her  father.  She  claimed  that  in  this  period  she 
had  no  fear  but  that  her  head  felt  dizzy  and  her  vision 
seemed  dim. 

At  the  Observation  Pavilion  the  patient  was  described  as  con- 
strained, refusing  food,  mute,  resistive  of  attention,  sometimes 
muttering  to  herself  and  having  the  appearance  of  uneasiness. 

Under  Observation :  1.  On  admission  the  patient  had  a  slight 
jaundice,  which  disappeared  in  a  few  days,  and  the  bile  test  in 
the  urine  was  negative  on  admission.  She  was  rather  thin,  but 
otherwise  in  good  physical  condition.  Her  temperature  was  99.2°. 

For  three  months  the  patient  was  very  inactive,  moving  very 
little.  She  had  to  be  dressed  and  undressed,  when  taken  out  of 
bed.  She  often  was  markedly  constrained,  either  lying  with  her 
head  raised  from  the  pillow,  or  for  long  periods  of  time  holding 
her  arms  or  hands  in  rather  constrained  positions  on  her  body. 
But  there  was  at  no  time  any  catalepsy  when  tested  by  moving 
her  arms.  In  the  beginning,  however,  before  she  lay  so  per- 
sistently with  her  head  raised,  she  was  found  holding  it  up  from 
the  pillow  after  her  hair  had  been  fixed.  Again,  she  did  not 
correct  other,  rather  uncomfortable,  positions  in  which  she  had 
been  left.  There  was  also  at  times  a  slight  or  occasionally  a 
somewhat  more  marked  resistance  in  her  arms  and  neck,  but  this 
never  amounted  to  a  pronounced  resistance.  She  sometimes  did 
not  react  to  pin  pricks,  sometimes  flinched  a  little,  never  warded 
off  the  pin,  indeed  she  would  put  out  her  tongue  repeatedly  when 
asked  to  do  so  in  order  to  have  a  pin  stuck  into  it.     She  very 


22  BENIGN  STUPORS 

often  wet  and  soiled,  once  even  immediately  after  she  had  been 
taken  to  the  closet,  on  which  occasion  she  did  not  urinate.  Her 
face  was  usually  dull,  vacant  and  immobile,  but  sometimes,  when 
questioned  or  when  something  obtrusive  happened,  a  little  puz- 
zled. Occasionally  she  looked  slowly  about  or  followed  people 
with  her  eyes.  There  was  no  evidence  of  any  affect  as  a  rule, 
but  not  infrequently  she  smiled,  even  quite  freely  at  times,  when 
the  physician  came  to  her  or  on  other  appropriate  occasions.  For 
example,  once  when  a  nurse  came  into  the  ward  whom  she  had 
known  outside  she  flushed  and  smiled  a  little.  Once  when  the 
mother  came  to  see  her  a  few  tears  appeared,  the  only  time  this 
occurred. 

Although  for  the  most  part  immobile,  when  she  did  move,  she 
was  distinctly  slow.  When  asked  to  do  certain  things,  she  usually 
did  not  comply,  but  now  and  then,  after  urging,  would  show  her 
tongue  after  delay,  or  merely  open  her  mouth;  or  she  would 
bring  the  hand  forward  slowly  when  the  physician  offered  his 
hand  in  greeting.  Once  she  fumbled  with  her  braids  slowly. 
When  out  of  bed,  she  stood  about  aimlessly  or  sometimes  walked 
somewhat  slowly. 

She  was  almost  entirely  mute,  but  a  few  times  she  returned  a 
greeting  quite  promptly,  or  on  another  occasion  (September  23) 
she  said  quite  promptly,  when  asked  how  she  felt,  "I  feel  better. 
I  took  off  my  clothes"  (correct — she  had  been  up  and  put  to  bed 
again).  Again  shg  sometimes  answered  simple  questions  by 
"yes"  or  "no,"  though  sometimes  in  a  contradictory  and  rather 
aimless  manner,  but  promptly  enough.  Once  she  said  to  her 
mother,  "I  can't,  I  have  to  remain  here."  There  were  some  other 
replies  which  we  shall  presently  take  up.  Several  times  it  was 
possible  to  make  her  write.  On  these  occasions  she  wrote  her 
name  promptly,  or  might  write  only  after  much  delay  or  stopping 
in  the  middle  of  a  word. 

This  leads  us  to  her  capacity  to  think,  the  defect  of  which  was 
perhaps  most  clear  in  her  writing.  Thus,  though  having  been 
told  to  write  her  name,  and  having  written  it  quickly  enough, 
when,  immediately  after  it,  she  was  asked  to  write  her  address  or 
the  name  of  the  hospital,  she  had  to  be  urged  much,  and  then 
wrote  each  time  merely  a  repetition  of  her  name,  this  time  much 
more  slowly.     On  October  13,  when  she  was  asked  to  write  her 


TYPICAL   CASES  OF  DEEP   STUPOR  23 

name,  she  wrote  it  correctly;  then  for  the  address  she  wrote  the 
house  number  correctly,  but  for  90th  street  she  wrote  "90theath" ; 
and,  urged  again  for  the  address,  she  added  "Dr.  Wyeth."  Again 
when  asked  to  write  the  word  "watch"  she  was  slow,  and  finally 
put  down  "10."  When  on  October  23  she  was  asked  to  write 
"Manhattan  State  Hospital,"  she  wrote  "Manhatt  Hhospshosh," 
and  for  "Ward's  Island"  (which  she  was  told),  "Ww  Hand." 
Then  she  was  asked  to  write  "I  wish  to  go  home."  She  wrote 
"I  wish  to  go  home,  go  West."  Here  again  the  first  part  was 
written  promptly. 

We  now  can  add  some  of  the  other  replies  which  she  gave. 
Once  she  was  asked  "Do  you  know  where  you  aref  She 
promptly  said,  "Yes."  ( Where  f)  No  reply.  On  another 
occasion,  at  the  initial  examination,  she  said  she  was  home  or 
"in  papa's  house."  Once  when  asked  "Do  you  know  me*?"  she 
said  "Yes."  (What  is  my  name?)  "Miss  D."  (her  name).  On 
the  occasion  on  which  she  had  stated  that  she  had  taken  off  her 
clothes,  she  was  asked  "Where  have  you  taken  off  your  clothes?" 
She  made  the  irrelevant  reply,  "That  was  the  girl  the  one  I  had." 

2.  Then  she  improved  somewhat.  On  January  5  she  walked 
about  a  little  more,  though  slowly,  and  still  looked  slightly 
puzzled  when  questioned.  She  spoke  more  readily,  counted 
promptly  though  once  stopped  in  the  middle  of  the  exercise.  In 
calculation  she  multiplied  correctly  3x7,  but  for  4x9  repeated 
the  21,  and  when  given  9x9  she  did  not  answer.  A  few  days 
later,  though  she  lay  again  motionless  with  her  head  raised  as 
before,  and,  as  she  had  sometimes  done,  smiled  brightly  when 
accosted,  she  gave  few  replies,  but  when  asked  to  write  down 
the  month  she  slowly  wrote  "December."  Asked  to  write  it  the 
second  time,  she  did  it  promptly.  She  also  replied  promptly  by 
saying  "Yes"  when  asked  whether  Christmas,  and  again  whether 
New  Year's,  had  passed,  but  did  not  reply  to  the  questions  how 
long  ago  Christmas,  or  how  long  ago  New  Year's,  had  occurred. 
On  January  23  she  was  decidedly  more  free  and  prompt  in  her 
replies,  yet  she  still  wet  and  soiled  (in  fact  this  did  not  cease 
until  the  end  of  the  month,  when  great  improvement  occurred). 
At  this  time  she  gave  quite  a  number  of  calculations  promptly, 
about  an  equal  number  w^-ongly.  She  knew  where  she  was,  knew 
the  names  of  a  number  of  people  about  her,  but  thought  she  had 


24  BENIGN  STUPORS 

been  here  about  two  weeks  (four  months),  and  gave  the  year 
and  the  date,  the  latter  as  the  28th  of  January.  When  then  told 
that  it  was  Thursday,  January  23,  and  that  she  must  remember 
it,  and  asked  five  minutes  later  what  she  had  been  told,  she  again 
said  "January  28"  and  left  out  Thursday.  To  some  questions 
to  which  she  did  not  know  the  answers,  since  she  had  an  amnesia 
for  the  time  of  their  occurrence  (the  incidents  of  coming  here), 
she  simply  remained  silent.  Even  on  February  7,  when  she  was 
much  freer,  helped  the  nurses,  and  said  herself  she  was  "smarter," 
she  had  difficulty  in  thinking,  said  she  was  17  (21),  gave  the  date 
of  her  birth  correctly,  but  the  current  year  as  1909  (1908)  and 
still  insisted  she  was  17.  She  then  did  the  calculations  on  paper, 
and  with  considerable  difficulty  got  correctly  "22."  But  she 
could  not  straighten  out  the  discrepancy.  At  that  time,  also, 
she  still  wrote  Hospitital,"  calculated  even  simple  multiplications 
with  some  mistakes,  could  not  get  the  point  of  a  story,  and  to 
retention  tests  gave  poor  results.  Indeed,  even  seven  days  later, 
when  she  wrote  a  very  rational  letter  and  appeared  quite  natural, 
she  made  some  omissions  in  her  writing,  and  a  few  mistakes  in 
spelling. 

However,  she  now  improved  rapidly,  and  by  March  31  she 
made  a  very  natural  impression,  was  frank,  free,  had  good  insight, 
calculated  well,  etc.,  understood  a  story,  retention  was  good. 

She  then  gave  the  retrospective  account  embodied  in  the  history, 
and  in  addition  told  that  she  had  no  recollection  of  going  to  the 
Observation  Pavilion,  the  coming  here,  or  the  first  part  of  her 
stay,  including  presentation  of  the  case  at  a  staff  meeting,  a 
physical  examination  and  a  blood  examination,  and  she  claimed 
for  a  long  time  not  to  know  where  she  was,  "I  was  in  a  kind 
of  dazed  condition."  She  also  said  she  could  not  understand 
the  questions  which  were  asked  her.  This  probably  refers, 
however,  to  the  second  part,  i.  e.,  the  partial  stupor  lasting  for 
two  months.  She  did  not  "feel  like  talking,"  the  limbs  "felt 
stiff-like." 

Case  5. — Annie  K.  Age:  22.  Admitted  to  the  Psychiatric 
Institute  January  7,  1907. 

F.  H.  The  father  was  an  alcoholic,  who  died  when  patient  was 
a  child.  A  paternal  aunt  had  a  nervous  breakdown,  with  recovery. 
The  mother  appeared  to  be  normal. 


TYPICAL  CASES  OF  DEEP  STUPOR  25 

P.  H.  The  mother  stated  that  the  patient  was  a  rather  delicate 
child.  She  attended  school  irregularly,  never  felt  much  interest 
in  it,  and  was  always  glad  to  be  at  home  and  help  the  mother 
take  care  of  the  other  children.  On  the  other  hand,  she  is  said 
to  have  been  quite  lively,  rather  a  tomboy,  with  a  temper.  She 
left  school  at  14;  learned  dressmaking  for  a  year,  but  did  not 
get  along  well.  Then  she  took  several  other  positions,  which 
she  held  for  about  a  year,  getting  on  pretty  well. 

She  married  at  20.  Her  husband  never  supported  her  well  and 
often  beat  her.  She  had  to  borrow  money  to  get  along  and 
worried  much.  During  pregnancy  she  seemed  to  worry  more, 
had  crying  spells,  and  often  seemed  absorbed  in  thought. 

Three  weeks  before  admission  she  gave  birth  to  a  child.  The 
labor  was  somewhat  difficult,  but  she  had  no  fever.  She  got  up 
on  the  tenth  day,  and  then  seemed  to  lose  all  interest,  did  not 
attend  to  the  baby,  said  she  was  not  strong  enough.  She  sat 
about,  appearing  depressed.  The  mother  then  took  her  and  the 
baby  to  her  house.  There  she  sat  or  walked  about,  said  very 
little.  But  she  repeatedly  came  to  her  mother,  said  she  had 
something  to  tell  her,  or  that  she  had  "done  something,"  although 
she  could  never  be  induced  to  say  what.  Once  she  came  to  her 
and  said,  "You  are  not  going  to  die."  She  often  moaned. 
Finally,  she  claimed  a  neighbor  had  been  saying  she  was  poisoning 
the  baby. 

The  patient  herself  gave,  after  recovery,  the  onset  as  follows : 
When  she  married  she  knew  her  husband  was  not  what  he  should 
be,  but  not  that  he  was  so  bad  as  he  proved  to  be.  He  was  a 
gambler,  did  not  support  her,  and  this  caused  her  much  worry. 
When  she  became  pregnant,  eight  months  after  marriage,  this 
increased  her  worry,  and  throughout  the  pregnancy  she  spoke 
much  to  a  neighbor  about  her  worries,  and  said  she  did  not  know 
how  she  could  manage,  pay  the  doctor,  and  the  like,  but  she  did 
not  say  much  about  it  to  her  mother  (because  the  latter  would 
have  made  such  a  fuss  about  it,  or  would  have  said,  "It  serves 
you  right").  Then  the  childbirth  came.  This  further  accentuated 
her  worries.  She  felt  her  difficult  circumstances,  wondered  how 
she  could  get  the  necessary  money,  "I  lay  there  worrying."  And 
she  claimed  she  did  not  sleep  at  all.  About  her  statement,  men- 
tioned by  the  mother,  that  she  had  done  something,  she  said  that 


26  BENIGN  STUPORS 

she  thought  she  had  poisoned  the  child  by  giving  it  fennel  tea, 
and  that  she  thought  a  neighbor  who  visited  her  said  she  had 
poisoned  it.  She  was  then  put  to  bed  again,  and  one  night  she 
had  a  vision  of  her  father.  This  frightened  her.  She  thought 
this  meant  he  had  come  for  her  and  she  wanted  to  die. 

At  the  Observation  Pavilion  she  was  dull,  staring,  resisting 
attempts  at  passive  motions. 

Under  Observation:  1.  There  was  nothing  noteworthy  in  her 
physical  condition,  except  for  a  rise  of  temperature  to  100° 
occasionally  during  the  first  month  of  her  admission.  For  the 
first  four  months  she  was  often  found  lying  in  bed  with  her  head 
half  raised  from  the  pillow,  or  standing  or  sitting  about  in 
constrained  positions,  immobile,  frequently  she  let  saliva  col- 
lect in  her  mouth.  She  usually  wet  and  sometimes  soiled  the 
bed.  Sometimes,  when  sitting  in  a  constrained  position,  she  let 
herself  gradually  slide  on  the  floor.  She  often  began  to  feed 
herself  when  urged,  but  would  not  finish,  and  had  to  be  spoon-fed, 
as  a  rule.  She  was  never  tube-fed.  She  was  often  quite  stiff 
and  showed  marked  resistance.  This  was  manifested  either  when 
passive  motions  were  tried,  at  which  times  she  usually  resisted 
passively,  i.  e.,  she  became  more  tense;  or  when  there  broke 
through  a  more  active  aggression  and  she  would  strike.  Above 
all,  the  opposition  showed  itself  towards  the  nurses'  attention; 
in  this  she  also  showed  either  a  passive,  aimless  opposition  and 
stiffness,  or  a  more  active  one;  but  even  in  the  latter  an  open 
show  of  angry  affect,  or  plain  irritation,  though  present  at  times, 
was  by  no  means  constant.  When  it  was  present,  she  would  strike 
quite  aimfully;  once  she  struck  the  nurse  and  said,  "You  are  the 
cause  of  it  all,"  and  once,  when  the  nurse  tried  to  give  her  some 
milk,  she  said,  in  an  irritated  tone,  "I  wonder  people  would  not 
let  me  alone  some  time."  Again,  she  bit  a  patient  who  tried  to 
hold  her.  On  another  occasion  she  quickly  jumped  up  and  pulled 
the  hair  of  a  patient  who  evidently  disturbed  her  by  her  noisy 
shouting.  As  was  stated,  she  usually  wet  the  bed,  resisted  being 
taken  to  the  toilet,  or  when  taken  there,  would  not  urinate  or 
defecate,  but  would  do  so  as  soon  as  she  was  returned  to  bed; 
or  she  urinated  while  standing.  The  same  perverse  opposition 
was  seen  when  she  would  refuse  a  glass  of  milk,  but  grab  it  when 


TYPICAL   CASES  OF  DEEP   STUPOR  27 

it  was  taken  away  and  then  refuse  to  let  go.  She  often  would 
grasp  the  bedclothes  or  other  things  and  hold  on  aimlessly. 

She  rarely  spoke,  answered  almost  no  questions,  complied,  as 
a  rule,  not  even  with  the  simplest  commands.  To  pin  pricks  she 
did  not  react  except  at  times  by  flushing.  But  she  did  not  stare, 
rather  looked  about,  and  was  at  times  easily  attracted  by  noises 
or  happenings  about  her,  and  would  then  look  in  that  direction 
not  without  some  interest.  Often  there  was  then  an  expression 
of  bewilderment.  Her  mood,  however,  was,  as  a  rule,  apathetic, 
but  at  times,  as  stated,  she  showed  some  anger.  Once  she  wept, 
and  a  few  times  she  smiled  or  snickered.  As  a  rule,  this  hap- 
pened without  appreciable  cause.  But  once,  when  a  cheering 
remark  was  made,  she  smiled ;  or,  when  her  picture  was  taken  (to 
show  the  peculiar  constrained  attitude  with  the  head  raised  from 
the  pillow),  she  laughed  loudly. 

Although  she  spoke  rarely,  she  made  a  few  utterances  in  the 
first  few  days.  Thus  she  suddenly  said :  "I  want  to  see  Mr.  N. — 
what  I  said  to  him  was  not  right,"  or  "Listen !  there  are  the 
priests  calling,"  or  "You  are  all  faking — it  is  me  that  done  it — 
they  are  all  dressing  up  downstairs,"  or  "I  told  you  she  was  not 
able  to  nurse  the  baby,"  or  "I  have  nobody,  I  am  lost — I  want  to 
know  the  truth — my  mamma,"  or  she  called  her  sister,  "They  are 
dead  since  last  night." 

Even  during  the  more  stuporous  state  she  could,  a  few  times, 
be  made  to  write  a  little.  Then  she  either  wrote  very  slowly  and 
not  more  than  a  letter,  or  if  she  wrote  more,  it  was  remarkably 
mixed  up.  Thus  when  asked  to  write  the  date,  she  wrote,  "Jane 
(mother's  name)  to  me  to  Chrichst,"  or  when  asked  to  write  her 
name:     "Annie  take  you  ktusto." 

As  to  her  orientation,  nothing  could  be  made  out  as  a  rule. 
At  first,  however,  a  few  weeks  after  admission,  she  spoke  cor- 
rectly of  the  month  as  January  and  spoke  of  the  Island.  When 
at  that  time  she  was  asked  if  she  had  a  baby,  she  said,  in  an 
annoyed  tone,  "I  don't  know." 

2,  In  the  beginning  of  May,  i.  e.,  four  months  after  entrance, 
her  condition  changed  somewhat,  and  for  two  months  she  pre- 
sented the  following  state:  She  stood  about,  or  walked  around 
slowly,  usually  with  her  arms  folded.  She  had  a  tendency  to 
stand  near  the  door.    She  had  to  be  assisted  in  dressing,  pushed 


28  BENIGN  STUPORS 

rather  than  led  to  her  meals,  and  urged  to  eat.  For  the  most 
part,  she  would  not  answer  questions,  but  would  either  smile  in 
a  sneering  way,  or  just  walk  away,  or  say,  "Oh,  don't  bother  me," 
or  "I  don't  want  to  talk,"  and  generally  her  attitude  was  rather 
sulky.  Nor  was  this  only  towards  the  physicians  but  towards 
the  husband,  sister  and  child  as  well.  When  on  May  17  the 
sister  came,  she  would  not  speak  to  her  but  said  "Go  away." 
The  baby  she  simply  pushed  away  sulkily  when  it  was  brought 
to  her.  To  the  husband  she  said  on  May  31,  "Go  away,  you 
stink."  In  the  first  part  of  this  period,  she  presented  some 
bursts  of  elation,  on  one  occasion  turned  somersaults,  indulged 
in  a  few  pranks  with  laughter,  or  once,  when  a  knock  at  the  door 
was  heard,  she  called  out  "Holy  gee,  cheese  it,  the  cop."  But 
these  occurred  only  in  the  first  part  of  the  period.  On  June  1 
she  spoke  to  the  nurse,  said,  "What  is  the  matter  with  these 
people,  they  must  be  crazy,"  asked  to  go  home,  and  was  then 
by  the  nurse  found  to  be  oriented,  and  to  know  the  names  of 
people  around  her.  But  when  she  was  asked  about  the  baby 
she  would  not  answer,  and  questioned  whether  she  was  not  mar- 
ried, she  said  "I  don't  know."  Yet  when  the  physician  desired  to 
talk  to  her,  she  was  just  the  same  as  before  and  remained  so  for 
two  more  weeks.  Another  somewhat  isolated  occurrence  was 
when  on  June  18  she  spoke  a  little  to  the  physician,  but  she  sat 
in  a  constrained  position  when  taken  into  the  office  and  answered 
many  questions  by  "I  don't  know,"  namely,  those  regarding  her 
condition  and  feelings,  the  questions  about  orientation,  about  her 
mother's  address,  and  her  child's  age;  but  when  asked  how  long 
she  had  been  married  she  said  correctly  "Two  years." 

At  the  beginning  of  July  she  improved  quite  rapidly,  and  on 
July  5  appeared  fairly  free  and  gave  a  fair  retrospective  account, 
with  some  urging,  and  it  was  thought  that  she  smiled  somewhat 
too  freely.  However,  on  July  27,  she  seemed  perfectly  well,  had 
normal  insight,  and  then  gave  the  second  retrospective  account, 
which,  together  with  the  first,  will  now  be  taken  up. 

Retrospectively:  She  claimed  to  remember  things  at  home, 
and  at  both  interviews  said  she  recalled  being  taken  to  the 
Observation  Pavilion.  While  there  she  thought  she  knew  where 
she  was,  remembered  that  she  did  not  talk.    She  had  a  feeling  she 


TYPICAL   CASES  OF  DEEP   STUPOR  29 

was  going  to  die  and  said  "I  thought  I  would  die  if  I  kept  still." 
However,  the  transfer  to  this  hospital  was  vague  in  her  mind,  as 
was  the  entrance  on  the  ward,  and  she  claimed  not  to  have  known 
for  quite  a  while  where  she  was.  She  added  that  she  used  to 
wonder  where  she  was,  how  she  had  gotten  here,  and  how  she 
could  get  out,  and  thought  the  questions  which  were  asked  were 
queer.  Individual  occurrences,  too,  specifically  inquired  into  were 
not  recollected,  such  as  an  examination  in  a  special  room.  Of 
the  mixed-up  writing  at  the  end  of  the  second  week,  she  had  no 
recollection  even  when  it  was  shown  to  her.  She  did  not  recall 
having  her  picture  taken  (with  eyes  open)  two  months  after 
entrance.  Yet  a  sudden  angry  outburst  ten  weeks  after  admission 
was  remembered.  She  stated  that  she  struck  the  patient  because 
the  latter  annoyed  her  by  her  shouting.  She  had  a  general  recol- 
lection of  being  stiff,  having  her  head  raised,  and  of  soiling  and 
drooling,  but  could  not  account  for  it.  She  felt  stubborn.  She 
also  claimed  not  to  have  been  hungry  and  not  to  have  felt  pin 
pricks. 

In  regard  to  ideas  which  she  had,  she  claimed  to  be  afraid  at 
first  that  she  would  be  cut  up.  She  remembered  repeated  visions 
of  her  father  at  night,  also  once  of  her  dead  aunt,  who  said 
"Come  to  me."  She  thought  she  was  in  a  cemetery,  all  the  family 
were  dead,  the  baby  dead.  In  the  beginning,  too,  she  sometimes 
heard  a  priest  whom  she  had  known,  say  "Be  good  and  God  will 
look  after  you." 

In  regard  to  the  later  period,  she  recalled  that  she  got  up  in 
May  and  felt  cross.  She  did  not  answer  because  she  did  not 
want  to  be  bothered.  She  pushed  the  baby  away  because  she 
did  not  think  it  belonged  to  her,  the  husband  because  she  did 
not  like  him.  (She  did  not  think  she  was  not  married.)  She 
evidently  remembered  the  visits,  thought  she  knew  where  she 
was,  knew  she  stood  near  the  door  "because  I  wanted  to  go  home." 
Besides  the  idea  that  the  baby  was  not  hers,  she  recalled  none, 
and  thought  she  had  no  hallucinations. 

She  was  discharged  perfectly  well  six  months  after  admission 
to  the  hospital.  Soon  after  that,  she  left  the  husband,  once  had 
him  arrested  in  1908  and  sent  to  the  workhouse.  She  was  again 
examined  in  1913,  and  was  found  to  be  perfectly  well,  and  she 
stated  she  had  been  well  since  the  discharge. 


30  BENIGN  STUPORS 

These  five  cases  will  have  to  suffice  for  the  present. 
They  were  given  in  full  in  spite  of  the  fact  that  we 
shall  leave  out  of  our  present  considerations  the 
history  of  the  cases  and  certain  of  the  stages,  and 
confine  ourselves  to  that  stage  of  each  case  which  is 
best  qualified  to  give  us  a  good  general  survey  of  the 
essential  features  of  the  stupor  reaction. 

These  phases  are:  stage  1  of  Case  1,  lasting  five 
months;  stage  3  of  Case  2,  lasting  one  year;  stage  2 
of  Case  3,  lasting  two  years;  stage  1  of  Case  4, 
lasting  three  months ;  stage  1  of  Case  5,  lasting  four 
months. 

We  gather  from  these  descriptions  that  the  essen- 
tials of  the  stupor  reaction  are  (1)  more  or  less 
marked  interference  with  activity,  often  to  the  point 
of  complete  cessation  of  spontaneous  and  reactive 
motions  and  speech;  (2)  interference  with  the  intel- 
lectual processes;  (3)  affectlessness ;  (4)  nega- 
tivism. 

Inactivity/:  There  is  a  complete  cessation  or  more 
or  less  marked  diminution  of  all  spontaneous  or  re- 
active movements.  This  includes  such  voluntary 
muscle  reflexes  as  contain  a  psychic  component.  For 
instance,  there  is,  often,  an  interference  with  swal- 
lowing (letting  saliva  collect  and  drooling),  winking, 
and  even  with  the  inhibitory  processes  used  in  hold- 
ing urine  and  feces  (soiling  and  wetting).  Often 
there  is  no  reaction  to  pin  pricks  or  feinting  motions. 
The  inactivity  also  often  interferes  with  the  taking 
of  food  so  that  spoon-feeding  or  tube-feeding  has  to 
be  resorted  to.    The  patient  may  keep  his  eyes  cov- 


TYPICAL   CASES   OF  DEEP  STUPOR  31 

ered  or  stare  vacantly,  the  face  often  presenting  a 
remarkably  immobile  wooden,  or  stolid,  expression. 
Complete  mutism  is  the  rule.  When  activity  is  not 
totally  interfered  with,  those  movements  which  are 
present  may  be  slow.  The  patient  may  have  to  be 
pushed  around  and  be  able  to  take  a  few  steps,  but 
soon  relapses.  More  often  they  are  of  normal  ra- 
pidity. Speech  then  may  also  be  slow  and  low,  but 
usually  shows  no  change  except  for  the  fact  that  it 
is  diminished  in  amount.  Sometimes  awkward  posi- 
tions are  assumed  and  retained,  and  there  may  be 
catalepsy. 

Negativism:  A  common  symptom  is  perverse 
resistiveness.  It  may  consist  in  a  marked  stiffening 
of  the  body  which  is  assumed  spontaneously  or  ap- 
pears only  when  attempts  at  interference  are  made, 
or  there  may  be  a  more  active  turning  away  or  even 
a  direct  warding  off,  sometimes  with  scowling  or 
anger  or  even  swearing  and  striking.  Retention  of 
urine,  which  is  seen  at  times,  should,  perhaps,  be 
mentioned  here.  Now  and  then  we  find  that  a  patient 
is  put  on  the  toilet  and  cannot  be  induced  to  urinate 
or  defecate,  while  soiling  and  wetting  occur  at  once 
on  returning  to  bed. 

The  intellectual  processes:  Little  is  known  about 
the  intellectual  processes  from  direct  observation  in 
these  more  pronounced  cases,  except  for  the  fact 
that  in  Case  5  questions  or  obtrusive  occurrences 
sometimes  produced  a  somewhat  puzzled  facial  ex- 
pression. Moreover,  the  patient  retrospectively 
stated  that  she  was  unable  to  understand  the  ques- 


32  BENIGN  STUPORS 

tions,  which  points  to  marked  difficulty  in  apprehen- 
sion. We  also  find  that  occasionally  there  is 
evidence  of  an  interference  with  the  intellectual 
processes  which  showed  itself  in  what  may  be  called 
'^paragraphic"  writing  when  the  patient  could  be 
induced  to  write.  Above  all,  we  see  that  retrospec- 
tively very  little  is  remembered  of  what  took  place 
during  the  stupor,  even  of  such  obtrusive  events  as 
the  moving  from  one  ward  to  another,  tube-feeding, 
physical  examination,  the  presentation  at  a  staff 
meeting,  and  the  like. 

Affect:  Complete  affectlessness  is  an  integral 
part  of  the  stupor  reaction.  Modification  of  the 
statement  will  later  be  mentioned.  The  patient  is 
indifferent  so  far  as  his  basic  condition  is  concerned, 
and  it  is  only  by  certain  stimuli  that  at  times  emo- 
tional reactions  can  be  elicitated,  some  tears  at  a 
visit  of  a  relative,  an  appropriate  smile  at  a  joke  or 
a  comical  situation  when  the  stupor  is  not  too  deep 
or  an  angry  reaction  called  forth  by  interference. 

Catalepsy:  Waxy  flexibility  or  merely  a  tendency 
to  maintain  artificial  positions  is  a  frequent  but  not 
an  essential  symptom. 

Physical  Condition:  Not  infrequently  we  find  in 
the  beginning  or  in  the  course  of  the  stupor  an  eleva- 
tion of  temperature  to  101°,  102°  or  even  103°.  In 
one  case  we  found  a  marked  cyanosis  in  the  extremi- 
ties. Case  2  showed  marked  loss  of  hair.  Gain  in 
weight  is  never  observed  and  marked  emaciation  is 
the  rule.  This  we  may  attribute  to  the  refusal  of 
food. 


TYPICAL   CASES  OF  DEEP   STUPOR  33 

A  perusal  of  these  cases,  then,  shows  that  the 
dominant  (and  well-nigh  exclusive)  symptoms  of  the 
stupor  are  inactivity,  apathy,  negativism  and  dis- 
turbance of  the  intellectual  functions.  Benign 
stupor  can  be  defined  as  a  recoverable  psychosis 
characterized  by  these  four  symptoms.  The  mean- 
ing of  such  vague  physical  manifestations  as  the  low 
fever  is  not  clear. 


CHAPTER  II 
THE  PARTIAL  STUPOR  REACTIONS 

The  cases  thus  far  considered,  namely,  those  of 
marked  stupor,  are  fairly  well  known  and  have  been 
studied  by  others.  Less  well  known  and  formulated, 
but  even  more  important  from  a  practical  as  well 
as  from  a  theoretical  point  of  view,  are  what  may  be 
called  partial  stupors. 

The  reader  has  noted  that  the  states  of  deep 
stupor  described  in  the  last  chapter,  did  not  end 
abruptly  with  a  sudden  return  to  health  or  a  sudden 
change  to  another  type  of  psychosis.  They  all 
gradually  passed  away,  not  by  the  disappearance  of 
one  symptom  after  another,  but  by  the  attenuation 
of  all.  Sometimes  a  more  or  less  stable  condition 
persisted  for  months,  in  which  there  was  no  stupor 
in  a  literal,  clinical  sense  but  when  apathy,  inactiv- 
ity, interference  with  the  intellectual  functions  and 
negativism  all  existed.  Had  these  been  the  only 
states  observed  in  these  patients,  there  might  have 
been  some  ground  for  doubt  as  to  the  diagnosis.  As 
it  was,  it  was  clear  that  we  were  dealing  with  mild 
stages  of  stupor.  When  a  psychiatrist  meets  with 
an  undeveloped  manic  state,  he  calls  it  a  hypomania 
and  does  not  hesitate  to  make  this  diagnosis  in  the 

34 


THE  PARTIAL  STUPOR  REACTIONS  35 

absence  of  complete  development  into  a  florid  excite- 
ment. This  procedure  is  not  questioned,  because  the 
manic  reaction  as  distinguished  from  a  mania  is  well 
recognized.  We  believe  that  there  is  just  as  dis- 
tinctive a  stupor  reaction  which  may  be  exhibited 
either  in  deep  stupors  or  what  we  may  term  partial 
stupors.  Theoretically,  complete  apathy,  inactivity, 
etc.,  make  up  the  clinical  picture  of  a  deep  stupor. 
When  these  symptoms  appear  rather  as  tendencies 
than  as  perfect  states,  a  partial  stupor  is  the  prod- 
uct. That  partial  stupors  occur  as  well-defined 
psychoses,  developing  and  disappearing  without  the 
appearance  of  deep  stupor,  we  shall  attempt  to  show 
in  the  following  three  typical  cases : 

Case  6. — Rose  Sch.  Age:  30.  Admitted  to  the  Psychiatric 
Institute  August  22,  1907. 

F.  H.  Both  parents  were  living  (father  74,  mother  68),  as 
were  two  brothers  and  two  sisters.     All  were  said  to  be  normal, 

P.  H.  Nothing  was  known  of  the  patient's  early  character- 
istics, except  that  she  herself  said  she  was  slow  at  learning  in 
school  and  did  not  have  much  of  an  education.  But  when  well 
she  made  by  no  means  the  impression  of  a  weak-minded  person. 
The  husband  had  known  her  for  ten  years.  He  married  her 
eight  years  before  admission,  by  civil  process,  keeping  this  from 
his  own  family  because  he  was  a  Jew  and  she  a  Christian.  He 
said  that  this  undoubtedly  worried  the  patient  at  times  and  that 
she  often  asked  him  when  he  would  take  her  to  his  family.  The 
patient  herself  later  also  said  that  this  used  to  worry  her. 
Finally,  one  and  a  half  years  before  admission  she  agreed,  on 
account  of  the  children,  to  accept  the  Hebrew  faith,  and  they 
were  then  married  in  the  synagogue.  But  he  still  did  not  take 
her  to  his  family. 

There  were  four  pregnancies :  the  first  child  died ;  of  the 
survivors  one  was  8,  a  second  5  years  old.    Finally,  a  year  before 


36  BENIGN  STUPOES 

admission,  she  became  again  pregnant.  During  the  pregnancy 
one  of  the  children  had  whooping  cough  and  she  herself  was 
thought  to  have  caught  it.  The  baby  was  born  three  months 
before  admission.  It  was  a  blue  baby  which  died  two  days  after 
birth.  The  patient  flowed  heavily  for  three  weeks  and  was  taken 
to  a  hospital,  where  she  continued  to  flow  intermittently  for 
some  weeks  more. 

Finally,  three  weeks  before  admission,  a  hysterectomy  was 
performed.  Several  days  after  this,  when  the  sister-in-law  visited 
her,  the  patient  begged  her  to  take  her  home,  said  the  doctor 
wished  to  shoot  her  and  to  give  her  poison.  Later  the  patient 
confirmed  this,  saying  that  she  thought  they  wanted  to'  give  her 
saltpeter,  and  that  she  heard  them  say  they  wanted  to  shoot  her. 

When  taken  home  she  refused  food ;  gazed  about,  was  absorbed, 
seemed  obstinate,  and  several  times  tried  to  jump  out  of  the 
window.  Retrospectively  the  patient  stated  that  she  heard 
children  on  the  street  call  "Katie."  She  thought  they  meant  her 
child,  heard  that  it  was  to  be  taken  away  from  her,  and  a  similar 
idea  again  came  out  later  in  her  psychosis,  namely,  that  somebody 
was  going  to  harm  her  children. 

At  the  Observation  Pavilion  she  appeared  stupid,  rather  im- 
mobile, her  attention  difficult  to  attract. 

Under  Observation :  On  admission  the  patient  appeared  sober, 
impassive,  moved  very  little,  was  markedly  cataleptic,  though  not 
resistive.  On  the  other  hand,  her  eyes  were  wide  open  and  she 
looked  about  freely,  following  the  movements  of  those  around  her 
not  unnaturally.  When  questioned,  she  looked  at  the  questioner 
rather  intently,  and  was  apt  to  breathe  a  little  more  rapidly,  and 
made  some  ineffectual  lip  motions  but  no  reply.  To  simple  com- 
mands she  made  slow  and  inadequate  responses.  She  flinched 
when  pricked  with  a  pin,  but  made  no  attempt  at  protecting 
herself.  She  had  to  be  spoon-fed.  The  catalepsy  persisted  only 
for  two  days. 

After  this  she  continued  to  show  a  marked  reduction  of  activity, 
moved  very  little,  said  nothing  spontaneously,  had  at  first  to  be 
spoon-fed  (later  ate  naturally  enough).  But  she  never  soiled 
herself  and  went  to  the  closet  of  her  own  accord. 

Emotionally  she  seemed  dormant  for  the  most  part,  though  for 
the  first  few  days  she  appeared  somewhat  puzzled,  and  one  night 


THE  PARTIAL  STUPOR  REACTIONS  37 

when  a  patient  screamed  she  seemed  afraid  and  did  not  sleep, 
whereas  other  nights  she  slept  well.  She  answered  only  after 
repeated  questions  and  in  a  low  tone.  Very  often,  though  her 
attention  was  attracted  easily  enough,  her  answers  were  remark- 
ably fallow  and  also  showed  a  striking  off-hand  profession  of 
incapacity  or  lack  of  knowledge.  This  was  often  without  any 
admission  of  depression  or  concern  about  her  incapacity.  She 
would  usually  say  "Whatf  or  "Hmf  or  repeat  the  question, 
but  most  often  would  say,  "I  don't  know,"  this  even  to  very 
simple  questions.  For  instance,  when  asked,  "What  is  your 
name?"  she  answered,  "My  name'?  I  don't  know  myself"  (but 
she  did  give  her  husband's  name),  or  when  asked  to  write  her 
name,  she  said,  "I  don't  know  how  to  write,"  or  "Call  Annie,  she 
will  write  my  name."  When  requested  to  read  or  write  (even 
when  asked  for  single  letters),  she  would  make  such  statements 
as  "I  can't  read."  However,  she  finally  named  some  objects  in 
pictures.  This  condition  was  characteristic  of  her  for  two  weeks. 
Then  her  condition  changed  a  little.  She  spoke  a  little  more 
freely  but  was  similarly  vague.  The  following  interview  of  Sep- 
tember 9,  is  characteristic :  When  asked  how  she  was,  she  said, 
"Belle."  (Are  you  sick?)  "No."  (Is  your  head  all  right?) 
"Yes."  (Is  your  memory  all  right?)  "Yes."  (Do  you  know 
everything?)  "Yes."  (Understand  everything?)  "Yes."  (Are 
you  mixed  up?)  "No."  (Do  you  feel  sick?)  "No."  But  when 
asked  where  she  was,  how  long  she  had  been  here,  what  the  name 
of  the  place  was,  what  was  the  occupation  of  those  about  her, 
she  said,  "I  don't  know."  (How  did  you  come  here?)  "I  couldn't 
tell  how  I  came  up  here."  (What  are  you  here  for?)  "I  am 
walking  around  and  sitting  on  benches,"  but  finally,  when  again 
asked  what  she  was  here  for,  she  said,  "To  get  cured."  She  now 
gave  and  wrote  her  name  and  address  correctly  when  requested, 
also  gave  the  names  of  her  children.  Yet  when  asked  about  the 
age  of  the  girl,  said,  "I  don't  know,  my  head  is  upside  down." 
When  an  attempt  was  made  to  make  her  repeat  the  name  of  the 
hospital,  or  the  date,  or  the  name  of  the  examiner,  she  did  so 
all  right,  but  even  if  this  was  done  repeatedly  and  she  was  asked 
a  few  minutes  later,  she  would  say  "I  couldn't  say,"  or  "I  forget 
things,"  or  "I  have  a  short  memory,"  or  she  would  give  it  very 


38  BENIGN  STUPORS 

imperfectly,  as  "Manhattan  Island,"  or  "Rhode  Island"  for 
"Manhattan  State  Hospital,  Ward's  Island."  (How  is  your 
memory?)  "All  right."  But  when  at  this  point  the  difficulty 
was  pointed  out,  she  cried.  (Why?)  "Because  I  forget  so 
easily."  All  this  was  while  her  general  activity  was  much  re- 
duced, and  she  seemed  to  take  very  little  interest  in  her  sur- 
roundings. 

Then  she  improved  somewhat,  asked  the  husband  some  ques- 
tions about  home,  and  on  one  occasion  cried  much  and  clung  to 
him  and  did  not  want  to  let  him  go  without  taking  her.  She 
also  began  to  work  quite  well,  but  still  said  very  little  spontane- 
ously. During  this  period  when  asked  questions,  she  spoke  freely 
enough,  but  seemed  somewhat  embarrassed.  What  was  still 
quite  marked  were  striking  discrepancies  in  giving  dates,  and  her 
utter  inability  to  straighten  them  out  when  attention  was  called 
to  them,  as  well  as  to  her  inability  to  supply  such  simple  data 
as  the  ages  of  her  children.  Her  capacity  was  later  not  gone  into 
fully  but  it  was  certainly  less  defective  on  recovery  than  at  this 
time.  She  was  rather  shallow  in  giving  a  retrospective  account 
during  this  period.  Even  later,  when  she  had  developed  a  clear 
insight  and  made,  in  respect  to  her  activity  and  behavior,  a 
natural  impression,  she  was  not  able  to  give  much  information 
about  her  psychosis,  although  she  apparently  tried  to  do  so. 

She  was  discharged  recovered  four  months  after  admission,  her 
weight  having  risen  from  93  lbs.  on  admission  to  133  lbs.  on 
discharge.  For  the  first  two  weeks  of  her  stay  in  the  hospital, 
her  temperature  varied  between  99°  and  100°. 

Retrospectively :  She  said  in  answer  to  questions  about  her 
inactivity  and  difficulty  in  answering  that  she  did  not  feel  like 
talking,  felt  mixed  up,  could  not  remember  well,  did  not  want 
to  write. 

Before  she  was  quite  well  she  knew  of  her  entrance  to  the 
Observation  Pavilion  and  her  transfer  to  Ward's  Island,  of  which 
she  could  give  some  details,  but  thought  she  had  been  in  the 
Observation  Pavilion  two  weeks  instead  of  three  days  and  in  the 
admission  ward  one  month  instead  of  a  few  hours.  As  to  the 
precipitating  cause  of  the  attack,  she  spoke  of  her  flowing  so 
much  after  childbirth  and  of  her  operation. 


THE  PARTIAL  STUPOR  REACTIONS  39 

She  was  seen  again  in  March,  1913,  when  she  seemed  quite 
normal  mentally  and  claimed  that  she  had  been  well  ever  since 
leaving  the  hospital. 

With  the  exception  of  negativism,  which  appears 
only  in  the  anamnesis,  all  the  cardinal  stupor  symp- 
toms are  found  in  this  history.  Particularly  note- 
worthy is  her  intellectual  deficiency  which  seemed 
to  be  made  up  of  a  real  incapacity  plus  a  remarkable 
disinclination  for  any  mental  effort  whatever.  It  is 
important  to  note  that  her  attitude  towards  this 
disability  was  usually  one  of  indifference  and  that, 
in  general,  there  was  no  show  of  affect  whatever. 
Freedom  of  speech  was  the  last  thing  for  her  to 
regain. 

Case  7. — Mary  C.  Age  26.  Single.  Admitted  to  the  Psychi- 
atric Institute  April  7,  1907. 

F.  H.  The  father  had  repeated  attacks  of  insanity,  from  which 
he  recovered,  but  he  died  in  an  attack  at  the  age  of  60.  A  sister 
also  had  a  psychosis,  from  which  she  recovered. 

P.  H.  The  patient  was  rather  quiet  and  easily  worried.  When 
14  she  had  some  dizzy  spells,  with  momentary  loss  of  conscious- 
ness. After  that  time  she  had  no  such  attacks,  except  after  a 
tooth  extraction  when  about  24. 

The  patient  came  to  the  United  States  six  months  before  ad- 
mission. She  went  to  live  with  a  cousin  who  died  a  week  after 
she  arrived  at  his  house.  She  worried  and  said  that  she  brought 
bad  luck.  Then  she  took  a  position,  where  she  was  well  liked, 
but  she  was  not  particularly  efficient.  In  this  situation  she  often 
felt  homesick  and  lonely. 

Two  weeks  before  admission  an  uncle  died,  which  affected  her 
considerably.  She  spoke  of  his  leaving  three  children,  and  would 
not  go  to  the  funeral.  Then  she  thought  she  was  going  to  die. 
She  felt  dizzy,  weak,  walked  with  a  stooped  position,  was  sleep- 
less.   In  the  midst  of  this  she  suddenly  felt  frightened  and  walked 


40  BENIGN  STUPORS 

into  her  mistress^  room,  to  whom  she  complained  that  some  one 
was  talking  outside  but  could  not  tell  what  was  said.  She  heard 
shooting.  Retrospectively,  after  recovery  the  patient  said  that 
at  that  time  she  suddenly  got  "mixed  up,"  and  that  her  "memory 
got  bad." 

She  was  taken  to  a  general  hospital,  where  she  thought  there 
was  a  fire,  and  screamed  "Fire!"  She  was  soon  transferred  to 
the  Observation  Pavilion,  where  she  appeared  dazed,  moving 
slowly,  yet  showing  a  certain  restlessness.  She  spoke  of  "the 
boat"  being  shut  up  so  that  no  one  could  go  out.  Again,  she  said 
"The  boat  went  down  and  all  the  people  keep  turning  up." 
Retrospectively  the  patient  stated  about  this  condition  that  she 
remembered  going  to  the  general  hospital  but  not  her  stay  at  the 
Observation  Pavilion.  (The  trip  to  the  Manhattan  State  Hospital 
was  again  clearer  to  her.)  About  the  ideas  she  had  at  the  time, 
she  remembered  only  that  the  room  seemed  to  go  around,  and  that 
after  she  had  come  to  the  Manhattan  State  Hospital  and  was 
clearer,  she  thought  she  was  in  Belfast,  was  on  a  ship,  and  that 
people  were  drowning. 

Under  Observation:  On  admission  she  had  a  temperature  of 
100°,  a  coated  tongue,  suffused  conjunctivae.  There  were  herpes 
of  the  lower  lip,  a  general  appearance  of  weariness  and  ex- 
haustion, a  flushed  face,  trace  of  albumen  in  the  urine,  which 
was  absent  on  the  third  day,  no  leucocytosis,  but  41  per  cent, 
lymphocytes. 

Then  and  henceforth  she  was  inactive  and  very  slow  in  all  her 
movements ;  she  never  stirred  spontaneously,  and  had  to  be  pushed 
to  the  toilet  and  to  the  table;  she  ate  slowly.  She  did  not  speak 
spontaneously,  and  her  replies  were  very  slow  in  coming.  She 
had  to  be  urged  considerably  before  she  would  speak  and,  as  a 
rule,  she  did  not  answer.  On  one  occasion  she  was  for  a  day 
totally  inactive  and  looked  duller.  That  day  and  on  a  few  other 
occasions  she  wet  the  bed.  There  was  at  times  an  appearance 
of  dull  bewilderment.  When,  soon  after  admission,  asked 
whether  she  felt  cheerful  or  downhearted,  she  said  "down- 
hearted," but  this  was  the  only  time.  Often  she  answered  "I  don't 
know,"  when  asked  whether  she  was  worried,  and  she  could  never 
say  what  she  was  worried  about.  Again  she  directly  denied 
worry.     Sometimes    she   smiled    appropriately,    and    repeatedly, 


THE  PARTIAL  STUPOR  REACTIONS  41 

when  asked  how  she  felt,  said,  "I  feel  better."  In  answer  to 
questions  as  to  how  her  head  was,  she  replied  several  times,  "My 
memory  is  gone,"  also  "I  can't  take  in  my  surroundings,"  or  "I 
don't  know  where  I  am,"  or  "I  cannot  realize  where  I  am." 
Again,  she  spoke  of  being  dizzy  and  once  said  it  was  as  though 
the  room  went  round.  Sometimes  she  knew  where  she  was  or 
knew  names,  again  said  "I  forget,"  but  she  always  was  approxi- 
mately oriented  as  to  time.  There  were  no  special  ideas  expressed 
and  no  hallucinations,  except  in  the  very  beginning  when  she  still 
thought  at  night,  when  she  heard  the  boats  on  the  East  River, 
that  people  were  being  drowned.  She  later,  as  stated  above,  said 
she  thought  she  was  on  a  boat  and  people  were  being  drowned. 

By  June,  i.  e.,  two  months  after  admission,  she  began  rhyth- 
mical swaying  of  the  body,  twisting  of  the  fingers,  or  pulling  out 
some  of  her  hair.  She  ascribed  this  behavior  simply  to  "nervous- 
ness." 

On  July  16,  after  a  visit  from  her  cousin,  who  said  to  her  that 
if  she  worked  she  would  soon  get  better,  she  began  spontaneously 
to  occupy  herself  somewhat.  She  became  more  active,  said  she 
felt  stronger  and  brighter,  and  that  her  memory  was  better.  By 
the  beginning  of  August  she  was  fairly  free,  but  still  spoke  in  a 
rather  low  voice,  although  answering  well.  Her  capacity  to 
calculate  also  remained  poor.  When  asked  about  the  more 
inactive  state,  she  said  she  had  been  afraid  to  stir.  (What  afraid 
of?)  "I  didn't  know  where  to  go  or  what  to  do."  Further,  she 
recalled  that  she  had  had  a  numb  feeling  in  her  tongue,  could 
not  speak  quickly,  and  that  her  mind  had  felt  confused  and  "she 
could  not  take  in  things."  Further  review  with  her  of  the  earlier 
period  of  her  psychosis  showed  that  there  was  a  blank  for 
external  events  and  most  of  the  internal  events  during  this  time. 

She  made  a  perfect  recovery  and  was  discharged  Aug-ust  7, 
1907,  four  months  after  admission. 

This  case,  although  very  like  the  last,  differs  from 
it  in  two  particulars.  For  one  day  her  symptoms 
were  sufficiently  marked  to  suggest  a  deep  stupor. 
Secondly,  her  intellectual  incapacity  was  not  so 
marked  (always  approximately  oriented  for  time) 


42  BENIGN  STUPORS 

and  with  this  there  was  some  subjective  apprecia- 
tion of  her  defect.  Apparently,  however,  this  in- 
sight did  not  cause  her  any  worry.  The  affectless- 
ness  was  equally  prominent  in  both  of  the  foregoing 
cases,  the  fact  that  Mary  C.  (Case  7)  once  admitted 
feeling  downhearted  in  response  to  leading  ques- 
tions, having  little  significance  in  the  face  of  her 
expression,  actions  and  usual  denial  of  worry.  It  is 
interesting  to  note  that,  during  the  bulk  of  her 
psychosis,  her  only  complaints  were  of  mental  hebe- 
tude and  dizziness.  Possibly  the  latter  was  merely 
an  expression  of  her  subjective  confusion. 

Case  8. — Henrietta  H.  Age:  22.  Admitted  to  the  Psychiatric 
Institute  March  6,  1903. 

F.  H.  The  father  stated  that  both  parents  were  living  and 
well,  also  eight  brothers  and  sisters. 

P.  H.  The  patient  came  to  this  country  when  she  was  a  baby. 
She  was  bright  at  school  and  industrious.  From  the  age  of  17 
on,  she  worked  in  a  drygoods  store  and  gave  satisfaction.  About 
her  mental  make-up  no  data  were  available,  except  for  the  state- 
ment that  she  always  made  a  natural  impression. 

When  21  (February,  1902),  without  known  cause,  she  broke 
down  and  was  sent  to  the  Manhattan  State  Hospital,  but  was 
not  observed  in  the  Institute  ward.  She  remained  in  the  hospital 
for  three  months.  It  was  claimed  that  the  attack  came  on  sud- 
denly two  days  before  she  was  sent  away.  She  suddenly  appeared 
anxious,  said  something  had  happened  and  became  excited.  This 
lasted  for  about  a  week,  and  then  she  was,  as  the  description 
says,  "depressed  and  cataleptic."  She  remained  in  this  condition 
for  about  a  month,  during  which  time  there  was  a  slight  rise 
of  temperature.  Then  she  improved  gradually  and  was  dis- 
charged three  months  after  admission.  After  recovery  from  the 
present  attack  the  patient  stated  that  during  the  first  sickness 
she  had  visions  of  dead  friends. 

She  was  perfectly  well  in  the  interval. 


THE  PARTIAL  STUPOR  REACTIONS  43 

Six  days  before  admission  she  suddenly  became  excited,  refused 
to  eat,  and  began  to  talk,  repeating  phrases  over  and  over.  Then 
she  became  elated  and  excited. 

After  recovery  the  patient  described  the  onset  of  her  psychosis 
as  follows:  Six  days  before  admission,  after  having  been  per- 
fectly well  and  without  any  known  cause,  she  was  feverish  and 
vomited,  but  slept  well.  Next  day  she  felt  nervous,  and  her 
thoughts  were  clear.  She  constantly  thought  of  dead  friends, 
heard  them  talking,  when  she  tried  to  do  anything  the  voices 
said,  "Don't  do  that."  She  also  thought  somebody  wanted  to 
harm  her  people.     Soon  she  started  singing  and  felt  happy. 

Then  she  was  sent  to  the  Observation  Pavilion^  where  she  ap- 
peared to  be  in  the  same  condition  which  was  observed  in  the 
Institute. 

Under  Observation :  1.  On  admission  she  was  in  good  physical 
condition,  except  for  her  skin  seeming  greasy.  She  presented  for 
nine  days  the  following  picture:  She  was  essentially  elated, 
laughing,  singing,  jumping  out  of  bed,  good-natured  and  tract- 
able, and  very  talkative.  Her  productions  showed  a  good  deal  of 
sameness  and  a  certain  lack  of  progression.  She  spoke  at  times 
in  a  rather  monotonous  voice,  but  again  often  in  very  theatrical 
tones,  with  much,  rather  slow,  gesturing.  The  following  are 
very  representative  samples: 

"I  have  been  suffering  from  my  own  blood,  my  own  blood  sent 
all  away  from  home.  I  just  came  from  Bellevue.  I  left  here 
last  May  (correct)  a  healthy  girl.  A  sister  is  a  sister — I  wonder 
why  shorthand  is  shorthand,  a  stenographer  is  a  stenogTapher 
(seeing  stenographer  write) — a  kind  brother,  Bill  H. — ^why  H. 
his  wife  is  a  sister-in-law  to  us,  she  has  four  children — four 
beautiful  children — ^sister-in-laws  and  brother-in-laws — telephone 
ringing  (telephone  did  ring) — dear  Lord,  such  a  remembrance — 
remembrance  was  remembrance,  truth  was  truth — honesty  is 
honesty — policy  is  policy — if  she  married  him,  she  is  my  sister- 
in-law  and  he  is  my  brother-in-law — Max  knows  me — she  changed 
her  name  to  Mrs.  R. — ^two  children  who  are  Rosie  and  Maud,  if 
names  were  given,  names  should  not  be  mistaken — they  are  Julia, 
Lillian — Rosie  and  Maud — why  should  wonders  wonder  and 
wonders  cease  to  wonder,  why  should  blunders  blunder  and 
blunders  still  blunder;  sleep  is  one  dream  and  dream  means  sleep 


44  BENIGN  STUPORS 

— if  move  is  moving,  why  not  move?"  When  she  accidentally 
heard  the  word  wine,  she  said  "Guilty  wine  is  not  in  our  house — 
wine  is  red  and  women  are  women,  and  women  and  wine  and 
wine  and  women  and  wine  and  song."  Again,  "You  are  not  Mr. 
Kratzberger,  Mr.  Steinberger,  Mr.  Einberger — you  are  not  Mr. 
Horrid  or  Mr.  Storrid — perhaps  you  are  Mr.  Johnson  or  Mr. 
Thompson — no,  you  are  Dr.  C."  (correct). 

She  was  quite  clear  about  her  environment. 

Although  the  mood  was  throughout  one  of  elation,  on  the 
ninth  day  in  the  forenoon  she  cried  at  times,  wanted  to  see  her 
mother,  and  spoke  in  a  depressed  strain  (content  not  known). 
A  few  hours  after  that  she  suddenly  became  quiet. 

2.  Then  for  four  days  (March  14-17)  she  was  markedly 
inactive,  though  at  times  got  out  of  bed.  She  looked  about  in  a 
bewildered  manner,  did  not  speak  spontaneously,  but  could  with 
urging  be  induced  to  make  some  replies.  She  did  this  now  fairly 
promptly,  now  quite  slowly.  Questions  were  apt  to  bring  on  the 
bewilderment.  Thus,  when  asked  where  she  was,  she  merely 
looked  more  bewildered,  finally  said  "Bellevue — I  don't  know," 
and  questioned  who  the  doctor  was  whom  she  had  called  by  name 
in  her  manic  state,  she  said,  with  some  bewilderment,  "Your  face 
looks  familiar."  (Where  have  you  seen  me?)  "In  New  York." 
She  claimed  to  feel  all  right.  There  was  no  real  affect.  She 
made  the  statement  that  at  home  she  heard  voices  saying  "You 
will  be  killed." 

3.  Henceforth  this  bewilderment  ceased,  and  for  16  or  17 
days  she  was  essentially  inactive  for  the  most  part,  for  a  short 
time  with  a  tendency  to'  catalepsy  and  some  resistiveness,  and  at 
that  time  lying  with  eyes  partly  closed.  As  a  rule  she  said 
nothing  spontaneously,  but  replied  to  some  questions,  usually 
with  marked  retardation,  again  more  promptly.  She  constantly 
denied  feeling  sad  or  worried,  repeatedly  said  she  felt  "better," 
only  on  one  occasion  did  she  cry  a  little.  When  asked  to  calculate 
she  sometimes  did  it  very  slowly,  again  fairly  promptly.  The 
simple  calculations  were  usually  done  without  error,  the  others 
with  some  mistakes.  As  to  her  orientation  the  few  answers 
obtained  showed  that  at  times  she  knew  the  name  of  the  place 
and  the  day,  again  she  gave  wrong  answers  (Bellevue).  Once 
asked  on  March  23  for  the  day,  she  said  April.     She  wrote  her 


THE  PARTIAL  STUPOR  REACTIONS  45 

name  promptly  on  one  occasion,  again  a  sentence  slowly  but 
without  mistakes.  Once  during  the  period  she  sang  at  night. 
Once  she  suddenly  ran  down  the  hall  but  quickly  lapsed  into  the 
dull  condition. 

On  April  4,  at  the  end  of  this  period,  she  suddenly  laughed, 
again  ran  down  the  hall,  said  she  had  done  nothing  to  be  kept  on 
Ward's  Island.  But  she  quickly  lapsed  again  into  the  dull  state. 
Later,  on  the  same  day,  when  the  doctor  was  near,  she  said,  in 
a  natural  tone,  "Thank  God,  the  truth  is  coming  out."  (What 
do  you  mean?)  "That  I  have  been  trusting  in  a  false  name  and 
that  Miss  S.  (the  nurse)  should  not  nurse  me."  Then  she  got 
suddenly  duller,  calculated  slowly  and  with  some  mistakes, 
3  X  17  =  41,  4  X  19  =  56,  and  when  asked  to  write  Manhattan 
State  Hospital  she  wrote  (not  very  slowly)  "Mannahaton  Hots- 
palne." 

4.  Next  day  it  was  noted  that  she  was  more  stuporous,  and 
she  remained  so  for  two  weeks,  now  showing  a  decided  tendency 
to  catalepsy  and  more  resistance  than  before,  though  not  marked, 
except  in  the  jaw.  She  lay  often  with  head  raised,  sometimes 
with  eyes  partly  open,  or  staring  in  a  dull,  dreamy  way,  neither 
soiling  nor  drooling,  however;  a  few  times  she  looked  up  when 
spoken  to  sharply.  There  was  no  spontaneous  speech.  Usually 
she  did  not  answer  at  all,  but  a  few  times  a  short  low  response 
was  obtained.  Once  she  wrote  slowly  a  simple  addition,  put 
down  on  paper.  When,  on  one  occasion,  asked  how  she  felt,  she, 
as  before,  said,  "I  feel  better." 

5.  Then,  with  the  exception  of  a  day  at  the  end  of  the  month, 
when  the  more  stuporous  state  was  again  in  evidence,  she  returned 
to  her  former  condition  without  catalepsy  or  resistiveness  and 
without  staring,  but  essentially  with  inactivity  or  slowness.  She 
now  even  dressed  herself,  answered  slowly  though  not  consistently, 
but  she  again  denied  feeling  troubled  or  sad,  "I  feel  better." 

On  July  7  she  got  brighter  but  was  still  rather  slow.  She  then 
even  began  to  do  some  work.     She  again  denied  feeling  sad. 

In  a  few  weeks,  while  having  a  temperature  of  102°  with 
vomiting  and  diarrhea,  she  suddenly  got  freer.  She  then  said, 
in  answer  to  questions,  that  she  did  not  speak  because  she  was 
not  sure  whether  it  would  be  right,  again  because  she  seemed  to 
lose  her  speech.     She  did  not  move  because  she  was  tired,  had  a 


46  BENIGN  STUPORS 

numb  feeling.  She  said  she  had  not  been  sad,  "but  I  had 
different  thoughts/'  "saw  shadows  on  the  walls  of  animals,  living 
people  and  dead  people."  She  was  not  frightened,  "I  just  looked 
at  them."  People  moved  so  quickly  that  she  thought  everything 
was  moved  by  electricity.  She  thought  her  head  had  been  all 
right. 

After  a  few  days  she  relapsed  into  a  duller  state  again,  but 
then  got  quite  free  and  natural  in  her  behavior.  On  August  28 
she  gave  a  retrospective  account  of  her  psychosis,  a  part  of 
which  has  been  embodied  in  the  history.  She  had  insight  in  so  far 
as  she  knew  she  had  been  mentally  ill.  She  claimed  to  remember 
the  Observation  Pavilion  and  her  coming  to  the  hospital,  also  the 
incidents  during  the  manic  state,  when  she  heard  cannon  and 
thought  a  war  was  on,  and  voices  she  could  not  recognize  nor 
understand.  Then  she  became  stupid,  although  neither  sad  nor 
happy. 

Then,  she  claimed,  she  got  stupid,  but  neither  sad  nor  happy. 
She  claimed  to  have  known  all  along  where  she  was,  but  felt 
mixed  up  at  times,  her  thoughts  wandered  and  she  felt  confused 
about  the  people.  She  thought  she  was  in  everybody's  way, 
thought  others  wanted  to  get  ahead  of  her,  did  not  speak  because 
she  did  not  know  if  it  were  right  or  wrong,  felt  she  might  cause 
disturbance  if  she  answered.  (It  is  not  clear  whether  she  had 
complete  insight  into  the  morbid  nature  of  these  statements.) 
She  also  claimed  again  that  all  along  she  "saw  shadows  on  the 
wall,"  "scenes  from  Heaven  and  Earth,"  "shadows  of  dead 
friends  laid  out  for  burial."  She  had  insight  into  the  hallucina- 
tory nature  of  these  visions.  Sometimes  she  thought  she  was 
dead  also.  She  claimed  that  she  began  to  feel  better  when  these 
shadows  stopped  appearing  in  June  (the  actual  time  of  her  im- 
provement). 

She  was  discharged  recovered  a  month  later,  after  having  been 
sent  to  another  ward. 

In  this  case,  then,  we  find  that  the  two  months  of 
stnpor  were  ushered  in  by  a  brief  state  in  which,  in 
addition  to  the  usual  inactivity,  there  was  a  certain 
bewilderment,    increased    by    questions,    while    the 


THE  PARTIAL  STUPOR  REACTIONS  47 

orientation  which  in  the  preceding  manic  state  had 
been  good  became  seriously  interfered  with.  The 
psychosis  bordered  on  deep  stupor  for  brief  periods 
when  the  inactivity  seemed  to  be  complete  or  she  lay 
in  bed  with  her  head  raised  from  the  pillow.  On 
the  other  hand,  there  were  occasional  sudden  spells 
of  free  activity  even  with  a  certain  elation.  She 
could  often  be  persuaded  to  answer  questions  or  to 
write,  the  slowness  of  this  spoken  or  written  speech 
varying  considerably.  Her  replies  revealed  the  fact 
that  she  was  essentially  affectless  and  that  her  in- 
tellectual processes  were  interfered  with,  even  to 
the  extent  of  paragraphic  writing.  We  have,  there- 
fore, here  again  features  similar  to  those  of  the 
preceding  cases.  In  addition  we  must  add  as  impor- 
tant that  this  patient  said  retrospectively  that  she 
thought  she  was  dead,  that  she  saw  '^shadows  from 
Heaven  and  Earth,''  ''shadows  of  dead  friends  laid 
out  for  burial, ' '  all  this  without  any  fear.  We  shall 
see  later  that  this  is  a  typical  stupor  content. 

We  will  here  include  state  3  of  Anna  G.  (See 
Chapter  I,  Case  1)  who  after  the  pronounced  stupor 
was  for  two  months  merely  dull,  somewhat  slowed 
and  markedly  apathetic.  Although  her  orientation 
was  not  seriously  affected,  there  was  considerable 
interference  with  her  intellectual  processes,  as 
shown  in  her  wrong  answers  or  her  lack  of  answers 
when  more  difficult  questions  were  asked. 

A  similar  picture  was  presented  in  state  2  of 
Mary  D.  (See  Chapter  I,  Case  4.)  Here,  to  be  sure, 
there  were  more  marked  stupor  features  in  that  the 


48  BENIGN  STUPORS 

patient  wet  and  soiled,  in  addition  to  occasional 
spells  when  she  lay  with  her  head  raised.  But  she 
spoke  and  acted  fairly  freely  (even  while  soiling). 
By  her  replies  she  showed  a  considerable  intellectual 
inefficiency,  although,  like  Anna  Gr.,  her  orientation 
was  not  seriously  disturbed.  Here  again  there  was 
complete  affectlessness. 

This  gives  us,  therefore,  ^ye  states  which  may  be 
analyzed  for  the  symptoms  of  partial  stupor.  The 
pictures  of  all  ^Ye  are  unusually  consistent.  There 
is  inactivity,  marked  but  not  complete;  poverty  of 
affect  without  perfect  apathy;  and  a  marked  inter- 
ference with  the  intellectual  processes.  The  last  can 
be  studied  better  than  in  the  deep  stupors  because 
these  partial  cases  are  more  or  less  accessible  to 
examination.  There  is  a  tendency  for  the  patient  to 
think  much  of  death  either  in  the  onset  or  during  the 
psychosis.  Negativism  seems  much  less  prominent 
than  in  the  deep  stupors. 

A  natural  criticism  is  that  these  cases  merely  had 
retarded  depressions.  Although  this  topic  will  be 
discussed  fully  in  a  later  chapter,  two  differential 
characteristics  should  be  mentioned  now.  First, 
depression  is  a  highly  emotional  state  in  which  the 
sadness  of  the  patient  is  as  evident  from  his  facial 
and  vocal  expression  as  from  what  he  says,  while 
these  stupor  reactions  are  by  observation  and  con- 
fession states  of  indifference.  Secondly,  there  is  no 
such  disturbance  of  the  intellectual  processes  in  de- 
pression as  is  here  chronicled.  Let  the  retardation 
once  be  overcome  so  that  the  will  is  exercised  and 


THE  PARTIAL  STUPOR  REACTIONS  49 

no  real  defect  is  demonstrable.  In  our  experience 
the  cases  of  apparent  depression  with  intellectual 
incapacity  are  found  on  closer  study  to  be  really 
stupors  as  other  symptoms  show. 


CHAPTEE  III 
SUICIDAL  CASES 

An  important  ''catatonic''  symptom  is  a  tendency 
to  sudden,  impulsive,  unexplainable  acts.  Such 
actions  occur  occasionally  in  benign  stupors  and, 
since  we  attempt  an  understanding  of  the  reaction 
as  a  whole,  an  effort  should  be  made  to  study  these 
phenomena  as  well.  The  cases  chosen  showed  per- 
sistent, quite  affectless,  yet  very  impulsive  attempts 
at  self-injury.  They  characterized  the  first  of  the 
three  cases  throughout,  were  present  in  one  stage 
(the  second)  of  the  second  patient,  while  in  the  last 
for  one  day  there  was  behavior  which  can  be  sim- 
ilarly interpreted. 

Mention  has  been  made  of  the  prominence,  ap- 
proaching universality,  of  the  death  idea  in  stupor. 
This  is  a  subject  to  be  discussed  in  length  presently, 
but  for  the  present  we  may  say  that  there  may  be  a 
delusion  of  death  with  dramatization  of  that  state 
or  a  mere  abandonment  of  the  mental  activities  of 
life.  It  is  but  a  step  from  corpse-like  behavior  to 
suicidal  attempts,  psychologically  speaking,  yet  this 
transition  necessarily  modifies  the  clinical  picture, 
since  one  necessitates  inactivity  and  the  other  ac- 
tivity. Secondarily,  other  atypical  clinical  features 
appear,  as  will  be  seen. 

50 


SUICIDAL  CASES  51 

Case  9. — Pearl  F.  Age:  24.  Admitted  to  the  Psychiatric  In- 
stitute July  26,  1913. 

F.  H.  A  paternal  aunt  was  insane.  Both  parents  died  long 
ago;  the  mother  when  the  patient  was  a  baby;  the  father  when 
she  was  a  girl.  She  came  to  this  country  when  17.  In  this 
country  she  had  generally  been  a  domestic.  An  older  brother 
and  sister  were  also  in  America. 

P.  H.  She  was  described  as  sociable,  good-natured,  bright 
enough,  not  inclined  to  be  depressed.  She  had  little  education. 
There  was  no  former  attack. 

Four  months  before  admission,  the  patient  did  not  menstruate 
but  was  said  not  to  have  worried  about  this.  A  month  later  she 
began  to  show  symptoms.  She  said  she  did  not  want  to  live,  had 
done  something  wrong  but  could  not  or  would  not  say  what  it 
was.  Again  she  said  a  young  man  was  going  to  sue  her,  a  young 
Jewish  fellow  whom  she  had  seen  only  a  few  times.  She  talked  of 
turning  on  the  gas.  She  also  complained  that  people  were  look- 
ing at  her  and  that  the  food  was  poisoned. 

The  patient  after  recovery  gave  the  following  version  of  the 
onset:  She  had  a  position  on  99th  St.  for  2^/2  years.  She  liked 
the  people  there  and  often  went  to  see  them  later.  Her  next  posi- 
tion was  in  the  Bronx.  She  was  there  for  nine  months.  In  the 
same  house  lived  "Harry."  After  the  work  she  used  to  talk  to 
him  in  the  yard  and,  after  she  left,  she  used  to  think  of  him  and 
long  for  him.  But  she  denied,  with  a  very  natural  attitude,  that 
she  worried  about  him  at  the  beginning  of  her  psychosis.  After 
the  position  in  the  Bronx  she  went  to  one  on  96th  St.,  where 
she  was  for  four  months.  In  the  same  house  was  a  girl  whom  she 
liked  and  who  was  lively.  When  she  left,  the  patient  left  too. 
This  was  a  month  before  the  psychosis  began.  When  she  left 
there,  she  got  word  that  her  employer  on  99th  St.  had  developed 
consumption  and  had  to  go  out  West,  but  did  not  worry  over  this 
news,  she  claimed.  She  looked  for  another  position  and  had  one 
for  two  weeks,  but  felt  lonely,  did  not  care  to  live.  Then  her 
sister  took  her  to  her  home.  She  thought  people  were  looking 
at  her  and  were  making  remarks  because  she  was  not  working. 
During  this  time  she  had  a  dream  one  night  in  which  her  dead 
mother  appeared  to  her  (in  ordinary  street  clothes)  and  said  to 
her  that  she    (the  patient)    "was  going  away."     She  woke  up 


52  BENIGN  STUPOES 

frightened.  She  was  worried,  thought  she  had  not  prayed  enough 
for  her  mother,  and  asked  her  sister  to  pray  also  and  to  give 
money  to  the  poor.  She  did  not  recall,  or  at  any  rate  denied, 
speaking  of  the  young  man  suing  her. 

She  was  then  taken  to  a  private  sanatorium^  where  she  was  for 
two  months  preceding  her  admission  to  this  hospital.  There  she 
was  described  as  quiet,  mute,  tube-fed,  resistive. 

When  well,  the  patient  said  that  in  this  sanatorium  she  was 
first  spoon-fed,  cup-fed,  later  tube-fed,  "I  used  to  be  scared  of 
them,  they  used  to  put  a  spoon  way  down  my  throat  and  I  had  no 
appetite — I  did  not  like  them  around  me,  they  were  mean  to  me. 
They  used  to  let  me  stand  without  clothes,  used  to  spite  me."  "If 
I  did  not  want  to  dress  myself,  they  used  to  hit  me."  "I  used 
to  feel  lonesome  for  home  and  I  imagined  my  people  were  there 
and  that  my  sister  passed  the  place  without  stopping."  She  was 
afraid  of  the  nurses,  thinking  they  wanted  to  kill  her. 

At  the  Observation  Pavilion  the  patient  was  described  as  dull, 
but  brightening  up  under  examination.  She  made  few  spontane- 
ous remarks,  but  in  answer  to  questions  said  she  was  melancholy, 
tired  of  life,  because  she  was  in  love  with  a  Gentile  fellow  who 
refused  to  marry  her.  She  also  said  "I  get  peculiar  thoughts 
that  I  am  going  to  die." 

Under  Observation:  The  patient's  condition  lasted  for  about 
two  years.  Much  of  the  time  she  lay  in  bed,  often  with  the  covers 
pulled  over  her,  sometimes  with  her  legs  drawn  up,  again  in  a 
more  natural,  comfortable  position,  or  she  sat  up  with  her  head 
bowed.  She  obeyed  almost  no  commands.  For  months  she  soiled 
and  wet  herself,  but  never  drooled.  For  a  time  she  refused  food 
consistently,  lost  flesh  and  had  to  be  tube-fed.  For  the  most  part 
she  said  very  little  and,  when  one  accosted  her,  she  was  apt  to 
turn  away.  A  few  times,  when  further  urged,  she  swore  at  the 
examiner.  There  was  also  persistent  marked  resistance  towards 
any  interference,  sometimes  merely  passive  or  quite  often,  espe- 
cially at  first,  with  wriggling  or  severe  scratching  of  her  own 
body.  There  was  often  with  this  evidence  of  irritation  or  she 
moaned.  Again  she  was  described  as  quite  affectless.  One  of 
the  most  striking  features  throughout  a  large  part  of  the  course 
were  her  suicidal  attempts.  She  would  try  to  strike  her  head 
against  the  iron  bedpost,  throw  herself  out  of  bed,  throw  herself 


SUICIDAL  CASES  53 

about  generally,  try  to  strangle  herself  with  the  sheets,  try  to 
pull  out  her  tongue,  all  of  which  seemed  to  be  done  with  great 
impulsiveness.  Almost  her  only  utterances  had  to  do  with  death. 
She  said  she  wanted  to  die,  wanted  to  drop  dead,  did  not  want 
to  live,  wanted  to  kill  herself,  that  she  did  not  eat  because  she 
wanted  to  die.  When  once  she  was  found  tossing  about  and 
was  asked  whether  she  worried,  she  said  "I  know  I  am  going  to 
die.*'     (You  mean  you  will  be  killed?)     "I  don't  care." 

There  were  a  few  episodes  which  still  have  to  be  mentioned. 
Quite  early  in  the  course  of  the  stupor,  when  she  was  restless, 
scratching  herself  and  moaning,  she  once  spoke  quite  freely.  She 
said  "Give  me  that  fellow  (Harry),  I  don't  care,  I  can't  help  it. 
I  must  have  him,  even  if  it  costs  me  my  life."  "I  would  feel 
happy  if  I  could  get  him.  0  God,  I  love  him — I  will  never  get 
him  even  if  I  drop  dead,  I  know  I  won't  get  him,  the  darling'^ 
(cries).  (What  if  you  did  get  him?)  "I  know  I  would  lose  him 
again."  Then  with  shame  she  claimed  she  had  had  sexual  rela- 
tions with  him  (when  well,  denied).  At  the  same  interview,  when 
the  doctor  sneezed,  she  said  "Gesundheit."  In  June,  1914,  when 
she  was  seen  smiling  at  times.  But  the  first  was  the  only  episode 
when  she  spoke  more  freely,  and  the  two  occasions  the  only  ones 
when  she  showed  a  frank  affect. 

The  improvement  commenced  in  April,  1915.  Although  still 
very  inactive,  she  sometimes  began  to  laugh  and  sing  and  talk 
a  little  to  other  patients.  She  also  answered  a  few  questions  on 
April  22,  1915.  Thus,  when  asked  whether  she  wanted  to  go 
home,  she  said  "No,  I  want  to  stay  here."  (Do  you  like  it  here?) 
"Yes"  (smiles),  I  can't  get  no  other  place;  I  have  got  to  like  it 
here."  She  smiled  freely.  To  orientation  questions,  she  knew 
the  place,  month,  but  not  the  year. 

She  continued  inactive  and  above  all  diffident,  but  improved 
steadily  and,  when  examined  by  the  writer  on  November  15,  she 
made  a  very  natural  impression  and  gave  the  retrospective  ac- 
count of  the  onset  embodied  in  the  history.  She  was  quite  frank, 
thanked  the  doctor  for  the  interest  he  took  in  her  case,  and  said 
for  example,  "You  know  I  never  thought  I  would  get  well.  I 
quite  gave  up — I  am  very  glad  I  am  well  now." 

When  questioned  about  her  stay  here,  the  patient  evidently 
remembered  much.     She  was  able  to  say  which  wards  she  had 


54  BENIGN  STUPORS 

been  in  and  approximately  how  long  she  had  been  in  each  one. 
She  claimed  that  at  first  it  "seemed  strange."  "I  did  not  eat,  I 
did  not  want  to  eat,  I  used  to  tell  them  to  poison  me  and  that  I 
wanted  to  die,  I  was  disgusted,  I  thought  I  would  never  go  home. 
She  also  says  she  felt  angry,  wanted  to  kill  herself.  She  bit  and 
scratched  "because  I  was  nervous."  She  remembered  talking 
about  Harry,  "I  said  I  was  in  love  with  him,  I  thought  I  wanted 
to  die  because  I  could  not  have  him."  She  also  talked  of  having 
been  stubborn.  Sometimes  she  felt  like  running  to  the  river.  She 
also  claimed  she  imagined  people  were  false  to  her. 

In  one  of  the  wards  she  said  she  thought  people  were  there  on 
her  account,  were  waiting  for  her  death.  She  did  not  care  for 
a  time  whether  she  died  or  not.  She  knew  she  tried  to  choke  her- 
self occasionally.  Asked  how  she  behaved,  she  first  said  she  was 
quiet.  (Were  you  not  restless?)  "I  used  to  get  tired  and  have 
backache  and  roll  around  in  bed."  She  also  felt  like  running 
away  sometimes,  wanted  to  get  out  of  bed  and  wanted  to  walk 
about.  (What  about  going  to  the  river?)  "I  used  to  say  that." 
She  claimed  not  to  have  been  mixed  up  at  any  time  and  to 
remember  everything.  Remarkable  is  the  fact  that  she  claimed 
she  did  not  worry  at  all,  "I  felt  I  was  lost  and  would  not  worry. 
I  used  to  worry  at  home  and  at  Dr.  M.'s  (the  private  sanatorium) 
but  not  here.  Here  I  never  worried,  I  did  not  care  where  I 
went."  She  said  she  did  not  talk  because  she  was  bashful  in  the 
presence  of  doctors,  sometimes  she  felt  afraid  of  them,  afraid 
they  would  kill  her,  put  poison  in  her  food  when  they  fed  her. 
"When  my  people  came,  I  said  I  did  not  want  to  live,  wanted  to 
kill  myself.  I  used  to  cry."  Again  asked  why  she  did  not  talk, 
she  admitted  she  really  did  not  know.  Once  she  said  she  was 
bashful  because  she  soiled  her  bed.  She  did  not  want  to  go  to 
the  closet  because  she  was  afraid  of  the  nurse.  She  denied 
hearing  voices. 

In  addition  to  the  activity  incidental  to  her  at- 
tempts at  self -injury,  this  patient  showed  an  unusual 
degree  of  resistiveness  and  with  this  some  affect, 
for  she  appeared  to  be  irritated  and  at  times 
moaned.    Still  more  unusual  were  the  appearances 


SUICIDAL  CASES  55 

of  delusions  not  associated  with  death  but  with  a 
vivid  form  of  life,  namely,  a  love  affair.  Occasion- 
ally she  spoke  of  her  imaginary  lover  ''Harry/' 
Another  atypical  feature  was  a  fair  memory  for  the 
period  when  she  was  in  stupor.  She  claimed  to  re- 
member much  of  her  movements  and  this  claim  was 
substantiated  by  her  answers  to  questions  after  re- 
covery. 

Case  10. — Margaret  C.  Age:  23.  Single.  Admitted  to  the 
Psychiatric   Institute  November  13,  1913. 

F.  H.  Heredity  was  absolutely  denied.  The  mother  is  living 
and  made  a  natural  impression.  The  father  died  at  65,  nine 
months  before  patient's  admission,  of  cardio-renal  disease.  Two 
brothers  and  one  sister  died  of  acute  diseases.  One  sister  died  in 
childbirth.     Three  brothers  and  one  sister  were  said  to  be  well. 

P.  H.  The  patient  was  bright  and  passed  successfully  through 
high  school.  For  seven  years  prior  to  the  psychosis  she  worked 
for  the  same  company  as  clerk.  She  was  described  as  efficient, 
conscientious,  systematic,  though  sometimes  upset  by  her  work; 
as  lively,  talkative,  cheerful,  with  somewhat  of  a  temper  and 
easily  hurt,  also  as  quite  religious.  She  was  more  attached  to 
her  mother  than  to  her  father,  but  still  more  to  her  older  sister, 
whose  death  precipitated  her  psychosis.  She  never  had  any  love 
affair  and  was  said  not  to  have  cared  for  men.  Two  months  be- 
fore admission,  when  her  favorite  sister  was  confined,  the  patient 
was  quite  worried  about  her,  but  relieved  when  she  heard  good 
news.  A  few  hours  later,  however,  the  sister  died  suddenly. 
When  the  patient  learned  of  the  sister's  death,  she  screamed,  and 
screamed  several  times  at  the  funeral.  She  did  not  cry,  said  she 
could  not.  After  this  she  slept  poorly,  seemed  nervous,  went  to 
church  more,  but  there  was  no  other  change.  She  continued  to 
work  and,  according  to  the  employer,  worked  well. 

Nine  days  before  admission  she  would  not  get  out  of  bed  in 
the  morning,  said  little  and  refused  food.  A  few  days  later  she 
was  induced  to  take  a  walk,  but  she  seemed  to  have  no  interest 
in  anything.    When  she  talked  at  all  it  was  about  her  sister  and 


56  BENIGN  STUPORS 

of  wanting  to  go  to  a  convent.  When  asked  to  do  anything  she 
said  she  would  if  it  were  God's  will.  She  did  not  menstruate 
after  her  sister's  death.  When  practically  recovered,  the  patient 
attributed  her  breakdown  to  this  tragedy.  She  added  to  the  de- 
scription above  given  that,  soon  after  losing  her  sister,  she  had 
a  fright  at  home.  "It  was  the  house  in  which  my  father  died 
and  one  day  when  I  was  in  bed  I  thought  somebody  came  in." 
But  she  denied  a  vision  and  could  not  further  explain. 

At  the  Observation  Pavilion  she  was  very  inactive,  so  that  she 
had  to  be  fed  and  cared  for  in  every  way,  mute,  often  covering 
her  head  with  a  sheet,  turning  away  when  questioned  and  re- 
sistive when  the  physical  examination  was  attempted.  But  at 
times  she  smiled  or  laughed. 

Under  Observation:  1.  For  two  months  the  patient  was  gen- 
erally inactive,  sometimes  lying  in  bed  with  her  eyes  tightly 
closed,  or  with  her  face  covered  by  the  sheets  or  buried  in  the 
pillow;  or  she  sat  inactive,  staring,  or  with  eyes  closed,  or  her 
head  buried  in  her  arms.  On  one  visit  she  had  to  be  brought  into 
the  examining  room  in  a  wheel  chair  and  lifted  into  another  seat. 
A  few  times  she  was  observed  holding  herself  very  tense  with  her 
head  pressed  against  the  end  of  the  bed.  But  this  inactivity  was 
often  interrupted  by  her  going  quickly  into  various  rooms  to  kneel 
down,  though  she  was  never  heard  praying.  Or  she  ran  down  the 
hall  for  no  obvious  reason.  Or,  again,  she  was  found  lying  on 
the  floor  face  down.  She  ate  very  poorly  and  had  to  be  tube-fed 
a  considerable  part  of  the  time.  When  this  was  done,  she  some- 
times resisted  severely,  as  she  did  in  fact  most  nursing  attentions. 
Thus  she  soon  began  to  struggle  when  her  hair  was  combed.  She 
also  resisted  being  taken  to  the  toilet  or  being  brought  back. 
She  did  not  soil  or  drool,  however,  but  sometimes  seemed  to  be 
in  considerable  distress  before  she  finally  literally  ran  to  the 
closet.  This  resistance  just  spoken  of  consisted  chiefly  in  making 
herself  stiff  and  tense.  Sometimes  at  the  feeding  she  pulled  up 
the  cover  when  preparations  were  made  and  held  to  it  tightly. 
Quite  striking  was  the  fact  that  with  such  resistance  she  some- 
times, though  by  no  means  always,  laughed  loudly,  as  she  did 
occasionally  when  she  was  talked  to,  or  even  without  any  external 
stimulation.  This  laughter  always  was  one  of  genuine  merriment 
and  quite  contagious,  and  by  no  means  shallow  or  silly. 


SUICIDAL  CASES  57 

Usually  the  patient  was  totally  mute.  The  exceptions  occurred 
mostly  when  her  resistance  was  called  forth.  Thus  one  day  when 
fed  she  said,  "I  wish  you  people  would  have  more  to  do/'  or  on 
another  occasion,  when  she  had  resisted  being  brought  into  the 
examining  room,  she  said,  "I  will  get  out  of  here  if  I  break  a  leg." 
But  once  when  the  nurse  accidentally  tickled  her,  she  said,  "Since 
I  am  ticklish,  I  must  be  jealous — I  should  worry."  She  also 
answered  very  few  questions  and  such  responses  as  she  made  were 
chiefly  expressions  of  resentment.  Thus,  when  one  kept  urging 
her,  she  finally  would  say  "stop,"  or  after  much  urging  "I  am 
going  to  hurt  you  pretty  quick."  Sometimes  she  said  "Go  away," 
or  "Let  me  alone."  She  was  just  as  silent  with  the  mother  and 
the  priest  as  with  the  physicians.  On  one  occasion  she  told  the 
nurse  that  the  priest  had  told  her  to  talk  to  the  doctors,  but 
that  she  had  nothing  to  say.  Sometimes  she  did  not  even  look 
at  the  visitors,  but  turned  away  from  them,  as  she  did  from  the 
physicians,  but  at  one  visit  from  a  priest,  though  she  scarcely 
said  anything,  she  held  on  to  him  when  he  was  about  to  depart 
and  would  not  let  him  go.  Throughout  this  period,  since  scarcely 
any  answers  were  given,  nothing  was  known  about  her  orientation, 
except  when  on  admission  she  gave  a  few  answers.  She  then 
thought  she  was  at  the  Observation  Pavilion,  seemed  unable  to 
tell  even  that  the  physician  was  a  doctor,  but  knew  the  date. 
When  asked  how  she  came  to  Ward's  Island,  she  said  "By  am- 
bulance." The  physical  condition  presented  nothing  of  note,  ex- 
cept for  a  certain  sluggishness  of  the  skin  with  marked  comedones. 

2.  By  January,  1914,  the  picture  changed  somewhat  and  she 
then  presented  the  following  state  for  an  entire  year:  The 
mutism  persisted  and  indeed  became  even  more  absolute,  and  she 
began  to  wet  and  soil  constantly.  This  commenced  as  what 
seemed  to  be  an  act  of  spite  as  a  part  of  her  resistiveness,  for 
the  first  time  she  soiled  she  seemed  to  do  it  deliberately  when  the 
nurses  insisted  that  she  allow  them  to  put  on  a  dress.  Later 
this  explanation  no  longer  held.  Tube-feeding  too  was  for  the 
most  part  necessary,  the  resistiveness  continuing  as  before.  But 
the  inactivity  was  broken  into  much  more  than  before  by  constant 
impulsive  attempts  to  hurt  herself  in  every  conceivable  way — ^by 
bumping  her  head  against  the  wall,  putting  her  head  under  the 
hot  water  faucet,  trying  to  pound  the  leg  of  the  bedstead  on  her 


58  BENIGN  STUPORS 

foot,  striking  herself,  pinching  her  eyelids,  pulling  out  her  hair, 
trying  to  pick  her  radial  artery,  throwing  herself  out  of  bed, 
knocking  her  head  against  the  bed  rail,  etc.  This  was  done  in 
silence  but  with  what  appeared  a  great  determination  that  oc- 
casionally showed  itself  in  her  face.  She  also  sometimes  scowled 
and  frowned.  With  the  difficulty  in  feeding  her  and  the  constant 
impulsive  excitement  in  which  bruises  could  not  always  be  avoided 
(once  an  extensive  cellulitis  developed  in  the  arm  which  had  to  be 
lanced),  the  patient  got  weak,  emaciated  and  exhausted;  much 
of  her  hair  fell  out,  although  some  she  pulled  out.  It  should  be 
stated  that  during  this  entire  impulsive  state  she  could  not  be 
taken  care  of  in  the  Institute  ward,  but  was  sent  to  a  special 
ward  in  the  Manhattan  State  Hospital,  where  suicidal  patients 
are  under  constant  watch.  These  impulsive  attempts  at  self- 
injury  lessened  only  towards  the  end  of  the  period.  Her  laughter, 
which  had  been  such  a  prominent  trait,  disappeared  almost  en- 
tirely during  this  entire  phase.  With  all  this,  the  general  re- 
sistiveness,  as  has  been  stated,  remained  towards  feeding  or  any 
other  interference.  It  was  only  in  the  beginning  associated  with 
laughter  as  in  the  previous  stage. 

Although  there  were,  as  a  rule,  no  spontaneous  remarks  and 
no  replies,  she  on  one  occasion  said  spontaneously,  probably 
referring  to  her  unsuccessful  attempts  to  kill  herself:  "I  can't 
do  it,  I  have  no  will."  During  the  same  period  she  once  said: 
"I  don't  want  to  eat,  I  don't  want  to  get  well,  I  want  to  do 
penance  and  die." 

By  January,  1915  (i.  e.,  a  year  after  the  second  phase  had 
commenced),  she  began  to  dress  herself  and  eat,  and  also  became 
clean.  But  she  remained  for  the  most  part  very  inactive,  sitting 
stolidly  about  all  day  and  still  without  interest  in  her  environ- 
ment. The  impulsive  attempts  at  killing  herself  disappeared. 
Although  she  remained  for  months  to  come  still  inactive,  she 
gradually  began  to  talk  a  little,  began  to  play  a  little  on  the 
piano,  but  said  little  to  any  one. 

By  August,  1915,  she  still  was  inactive,  shy,  standing  about, 
or  sitting  picking  her  fingers,  occasionally  going  to  the  piano, 
but  evidently  unable  to  finish  anything.  She  had  to  be  coaxed 
to  come  to  the  examining  room  and  talked  in  a  low  tone.  Often 
she  commenced  vaguely  to  speak  and  then  stopped  and  could  not 


SUICIDAL  CASES  59 

be  made  to  repeat  what  she  had  been  saying.  Affectively  she 
was  remarkably  frank,  sometimes  a  little  surly,  or  she  showed 
a  slight  empty  uneasiness.  She  could,  however,  be  made  to  laugh 
heartily  at  times,  or  did  so  spontaneously  on  very  slight  provo- 
cation. 

Some  of  her  utterances  were  in  harmony  with  her  apparent 
indifference.  It  was  diflacult  to  get  her  to  say  how  she  felt 
even  when  thorough  inquiries  were  made.  Once  she  said,  when 
asked  about  worrying,  "I  don't  worry,"  or  again  "I  get  angry 
sometimes,"  or  "I  used  to  worry  about  my  health,  I  don't  now," 
or,  when  asked  what  her  plans  were,  she  said  directly:  "I  don't 
care  what  happens."  Again  she  said  "I  guess  I  am  disagree- 
able," or  "I  guess  I  am  a  crank."  Another  interesting  indica- 
tion of  her  state  was  expressed  in  her  repeated  statement,  "I 
don't  know  what  I  want."  But  she  was  oriented  in  a  way, 
though  not  sure  of  her  data.  She  would  give  most  of  her  an- 
swers with  a  questioning  inflection,  "This  is  the  Manhattan  State 
Hospital,  isn't  it  f"  or  she  would  say,  "I  don't  know  exactly  where 
I  am,  it's  Ward's  Island,  isn't  if?"  and  in  the  same  way  she  gave 
the  day,  date  and  year  correctly.  But  she  did  not  know  the  names 
of  the  physicians.  At  that  time  she  could  give  many  data  about 
her  family  correctly,  but  was  slow,  even  if  correct,  in  calculation, 
and,  though  she  got  the  gist  of  a  test  story,  she  left  out  some 
important  details. 

A  retrospective  account  at  that  time  showed  she  was  uncertain 
about  the  Observation  Pavilion,  that  she  was  not  certain  how  she 
came  to  Ward's  Island,  "On  a  boat,  I  believe."  It  was  clear  that 
she  did  not  remember  the  admission  ward,  about  the  Institute 
ward  (in  which  she  had  been  for  the  first  two  and  a  half  months 
and  in  which  she  was  again  examined) ;  she  said  it  was  familiar 
to  her,  but  she  was  not  certain  that  she  had  been  in  it.  About 
the  physician  who  saw  most  of  her  in  these  first  two  and  a  half 
months,  she  said  that  his  voice  seemed  familiar,  and  she  asked 
him  whether  he  had  tube-fed  her  (she  had  been  tube-fed  by  him 
many  times),  but  she  again  said,  "No,  you  are  not  the  one,"  and 
described  as  the  man  who  had  fed  her  the  one  who  did  it  on  the 
second  ward  where  she  was  for  a  year.  But  she  knew  that  she 
had  been  sent  to  the  second  ward,  because  she  constantly  tried 
to  injure  herself.     These  injuries  she  recalled  but  was  unable 


60  BENIGN  STUPORS 

to  say  why  she  attempted  them,  "I  suppose  I  didn't  know  what 
I  was  doing."  She  claimed  she  heard  voices  and  had  "all  sorts" 
of  imaginations,  but  could  not  be  gotten  to  tell  about  them. 
When  it  was  difficult  for  her  to  give  an  answer,  she  was  apt  to 
keep  silent  and  then  could  be  prodded  without  much  success. 

In  October,  1915,  there  was  further  improvement,  inasmuch 
as  she  began  to  converse  some  with  other  patients,  played  the 
piano  and  seemed  able  to  carry  a  piece  through.  She  was  put 
in  the  occupation  class  and  did  quite  well.  At  the  interview 
with  the  physician  she  was  still  apt  to  laugh  boisterously  at 
slight  provocation.  Even  now  she  had  great  difficulty  in  describ- 
ing her  condition  and  at  the  examination  was  often  still  quite 
vague.  Thus,  when  asked  how  she  felt,  she  said,  "I  do  know  I 
feel  ridiculous — sometimes  I  feel  kind  of  angry — I  don't  know — 
they  say  I  am  crazy  but  I  am  not,  but  I  am  hungry — I  don't 
know  whether  I  am  or  not,  I  don't  know  what  I  can  do  well," 
etc.  This  is  quite  characteristic.  When  asked  whether  she  was 
worried,  she  said:  "I  don't  know,  am  I  worried? — ^yes,  a  little 
sometimes,  I  am  to-day — I  am  so  untidy — don't  know  what  is 
the  matter  with  me."  Again :  "Sometimes  I  lose  my  speech — I 
can't  say  what  I  feel,  I  don't  know  what  it  was."  Later,  half 
to  herself:  "I  don't  know  what  is  the  matter  with  me — I  don't 
care  anyway." 

In  December,  1915,  there  was  still  further  improvement,  and  on 
the  ward  and  in  superficial  conversation  she  made,  towards  the 
end  of  the  month,  in  many  ways  a  natural  impression,  though 
the  laughter  before  described  was  still  somewhat  in  evidence. 
It  usually  came  not  without  occasion,  but  was,  as  a  rule,  quite 
out  of  proportion  to  the  stimulus.  She  again  said  she  could 
not  explain  why  she  tried  to  injure  herself,  claimed  she  did  not 
feel  it,  and  even  claimed  she  did  not  remember  doing  it  in  the 
Institute  but  only  in  the  second  ward. 

The  defect  in  thinking  which  still  remained  is  very  difficult  to 
formulate.  She  was  now  entirely  oriented,  no  longer  with  any 
hesitation  about  the  correctness  of  her  information.  She  sub- 
tracted 7  from  100  very  quickly  and  could  from  memory  write  a 
long  poem,  but  there  was  a  certain  vagueness  about  her  which 
partly  may  have  been  due  to  a  still  existing  indifference.  This 
vagueness  consisted  chiefly  in  a  difficulty  of  attention  or  in  her 


SUICIDAL  CASES  61 

capacity  to  grasp  fully  what  was  wanted.  It  is  best  illustrated  by 
a  few  examples :  After  she  had  been  asked  about  the  onset  of  her 
sickness  and  she  had  said  that  what  was  on  her  mind  then  were 
prayers  for  the  salvation  of  her  relatives,  she  was  asked  exactly 
when  it  was  that  she  thought  of  this;  she  answered  "Now?" 
(What  period  were  we  talking  of,  the  present  or  past?)  "The 
present."  (What  did  I  ask  you?)  "About  this  period  of  my 
sickness."  (Which  one?)  "What  sickness?"  She  said  herself 
at  this  point,  "I  am  rather  stupid"  (quite  placidly).  Or  again 
she  said  she  did  not  know  why  she  pounded  her  head,  but  finally 
said,  "To  get  better  and  go  home."  (Do  you  think  if  you 
pounded  your  head  against  the  wall  you  would  go  home  sooner?) 
"I  don't  know — maybe."  (How  would  it  help  you?)  "You 
mean  to  go  to  the  city?"  (Yes.)  "I  don't  know."  Again  when 
asked  how  her  mind  worked,  she  said,  "Pretty  quickly  sometimes 
—I  don't  know."  (As  good  as  it  used  to?)  "No,  I  don't  think 
so."  (What  is  the  difference?)  This  had  to  be  repeated  sev- 
eral times,  at  which  she  said,  "There  is  no  difference."  (What 
did  I  ask  you?)  "The  difference."  (The  difference  between 
what?)  "You  did  not  say."  Equally  striking  was  the  fact  that 
when  she  was  jokingly  told  "If  it  snows  to-night,  we  shall  have 
a  black  Christmas,"  she  did  not  grasp  the  absurdity  at  once, 
but  in  a  rather  puzzled  way  asked,  "Why?" 

She  was  then  discharged  on  parole,  two  years  and  one  month 
after  admission.  Soon  after  discharge  her  menstruation,  which 
had  been  absent  throughout  her  psychosis,  returned.  On  her 
discharge  she  had  regained  her  normal  weight,  and  during  the 
two  subsequent  months  gained  fifteen  pounds. 

She  then  recovered  completely,  so  that  three  months  after 
discharge  she  made  a  very  natural  impression.  She  said,  on 
looking  back  over  her  state  with  impulsive  excitement,  that  she 
constantly  had  the  idea  that  she  wanted  to  punish  herself,  but 
that  she  did  not  know  why,  and  did  not  think  she  was  sad  oi 
worried. 

Considering  only  the  second  phase  of  the  psycho- 
sis, this  deep  stupor  showed  many  interruptions,  due 
not  merely  to  her  suicidal  efforts  but  also  to  her 
resistiveness.    The  condition,  too,  was  not  so  com- 


62  BENIGN  STUPORS 

pletely  affectless  as  one  expects  a  deep  stupor  to  be. 
In  the  first  stage  there  was  much  sudden  laughter, 
reminding  one  of  dementia  praecox  (except  for  its 
never  being  shallow  or  silly)  and  this  persisted  into 
the  first  part  of  the  second  phase.  The  actual  at- 
tempts at  self -injury  brought  out  emotion,  for  with 
them  she  scowled  and  frowned  as  well  as  showing 
considerable  energy. 

To  these  may  be  added  the  following  case.  It  is 
not  unlike  the  ordinary  stupor  in  the  fact  that  there 
was  intense  inactivity  and  mutism  with  great  tense- 
ness. The  remarkable  trait  was,  however,  that  for 
a  whole  day  she  forcibly  held  her  breath  until  she 
got  blue  in  the  face.    The  case  in  detail  is  as  follows : 

Case  11. — Rosie  K.  Age:  18.  Admitted  to  tlie  Psychiatric 
Institute  January  24,  1907. 

F.  H.  Both  parents  were  living.  The  father  was  a  loafer. 
Nine  brothers  and  sisters  were  said  to  be  well,  with  the  excep- 
tions of  one  brother  who  had  an  irritable  temper,  and  of  a 
markedly  inferior  sister. 

P.  H.  The  patient  was  a  Galician  Hebrew,  a  shirtwaist  opera- 
tor. Not  much  was  known  about  her  make-up,  but  it  is  certain 
that  she  was  a  bright  girl.  The  patient  herself  said  after  recov- 
ery that  her  father  was  nagging  her  constantly  with  complaints 
that  she  was  not  making  enough  money,  although  he  himself  did 
not  work  and  she  contributed  much  to  the  support  of  her  family. 
She  disliked  him  very  much  and  claimed  that  all  her  relatives 
worried  her,  except  her  mother. 

Nine  weeks  before  admission  a  messenger  came  into  the  shop 
where  she  worked  and  said,  "Rosie,  your  father  is  dead"  (the 
message  was  intended  for  a  fellow  worker).  In  spite  of  the 
fact  that  the  matter  was  explained,  she  was  upset  and  nervous 
enough  to  be  taken  home.  Though  she  continued  to  work  for 
over  two  weeks,  she  worried  over  many  trivial  matters  and  talked 


SUICIDAL  CASES  63 

much  about  this.  She  also  said  that  everything  looked  queer  at 
her  home  and  complained  of  having  difficulty  in  concentrating 
her  mind.  Finally  she  became  elated  and  talkative.  Nothing  is 
known  of  any  special  ideas. 

At  the  Observation  Pavilion  she  appeared  to  be  typically 
manic. 

Then  she  was  sent  to  an  institution  where  she  remained  for 
six  weeks.  The  report  from  there  stated  that  she  was  for  ten 
days  "elated,  excited,  talkative,  with  flight  of  ideas."  Then  her 
condition  suddenly  changed  to  a  marked  reduction  of  activity,  in 
which  she  neither  spoke  spontaneously  nor  answered  questions. 
She  "appeared  to  sleep,"  but  was  said  to  have  talked  to  her 
people.  When  interfered  with,  she  was  resistive  and  sometimes 
let  herself  fall  out  of  bed.  On  the  other  hand,  she  occasionally 
wandered  about  at  night.  It  should  be  added  that  during  the 
stupor  an  alveolar  abscess  developed  which  discharged  pus.  It 
was  washed  out  and  healed. 

Then  she  was  sent  to  the  Manhattan  State  Hospital  and  ad- 
mitted to  the  service  of  the  Psychiatric  Institute. 

Under  Observation:  1.  On  the  first  day  she  lay  in  bed  with 
cyanotic  extremities,  weak  pulse,  grunting,  moaning  and  not  re- 
sponding in  any  way  when  examined.  After  this  the  moaning 
and  grunting  ceased  and  she  was  essentially  indifferent,  and  for 
the  most  part  kept  her  eyes  closed.  Often  she  wet  and  soiled 
herself.  She  was  resistive  to  any  care  or  examination.  She 
would  not  eat,  as  a  rule,  but  again  gulped  down  milk  offered  her. 
For  a  considerable  time  she  had  to  be  tube-fed.  During  the 
early  part  of  this  stupor  she  once  took  a  paper  from  the  doctor, 
examined  it,  and  then  gave  it  back  without  saying  anything,  or 
again  she  peered  around  silently,  or  asked  to  go  home,  or  again, 
on  a  few  occasions,  answered  a  question  or  two  or  spoke  some 
unintelligible  words.     Orientation   could   not   be   established. 

2.  After  a  few  weeks  she  became  more  rigid,  a  condition  which 
continued  for  six  months.  She  let  saliva  collect  in  her  mouth, 
and  drooled.  She  had  to  be  tube-fed.  She  lay  very  rigid,  with 
very  pronounced  general  tension,  with  her  lips  puckered,  hands 
clenched,  sometimes  holding  her  eyes  tightly  closed,  and  often 
with  marked  perspiration.  For  one  day  she  held  her  breath  until 
she  was  blue  in  the  face.     On  the  same  day  she  was  extremely 


64  BENIGN  STUPORS 

rigid,  so  that  she  could  be  raised  by  her  head  with  only  her  heels 
resting  on  the  bed.  Her  eyes  were  tightly  shut  and  she  was  in 
profuse  perspiration.  Sometimes  she  interrupted  this  by  a  deep 
breath,  only  again  to  resume  the  forcible  holding  of  her  breath. 
On  another  day  towards  the  end  of  the  period,  while  quite  stiff, 
she  kept  grunting  and  screaming  "murder."  The  soiling  contin- 
ued.    She  never  spoke. 

Physical  condition  during  the  stupor.  At  first  she  had  a  coated 
tongue,  foul  breath  and  a  fetid  diarrhea.  The  latter  was 
treated  with  high  colonic  flushing  and  mild  diet.  Urine  normal 
— gynecologically  normal.  General  neurological  and  physical  ex- 
amination not  possible.  At  the  same  time  she  had  for  two  weeks 
a  temperature  which  often  reached  100°  or  a  little  above,  a  weak, 
irregular  but  not  rapid  pulse,  a  leucocytosis  of  17,500  and  80% 
hemoglobin.  When  she  began  to  refuse  food  and  before  she  was 
tube-fed  regularly,  she  twice  had  syncopal  attacks  and  lost  con- 
siderable flesh  which  was  gradually  regained  under  tube-feeding. 
After  the  diarrhea  she  was  habitually  constipated.  Cyanosis 
of  the  extremities  seemed  to  have  been  present  only  at  first. 

3.  Six  months  after  admission  she  began  to  make  very  free 
facial  movements — ^winking,  raising  the  eyebrows — and  soon  de- 
veloped an  excitement  with  marked  elation.  She  had  to  be  kept 
in  the  continuous  bath,  talked  continuously,  whistled,  sang,  was 
markedly  erotic  towards  the  physician,  careless  in  exposing  her- 
self and  often  obscene  in  her  talk.  Most  of  her  productions 
were  determined  by  the  environment.  She  was  therefore  quite 
distractible,  very  alert;  sometimes  she  was  meddlesome,  again 
irritable,  irascible.  The  following  illustrates  her  productions: 
"Send  for  my  husband,  S. — He  had  one  sister  as  big  as  that. 
She  likes  candy.  .  .  .  My  father  is  underneath  and  my  mother  is 
on  top  because  she  is  fat  and  he  is  skinny.  .  .  .  Wait  till  the 
sun  shines,  Nellie — we  will  be  happy,  Nellie — don't  you  sigh, 
sweetheart,  you  and  I — wait  till  the  sun  shines  by  and  by.  .  .  . 
Come  in  (as  noise  is  heard) — I  bet  that  is  my  husband — ^my  name 
is  Regina  K.  (mother's  name) — ^my  mother's  name  is  the  same 
— I  got  a  little  sister  named  Regina — she  is  my  husband."  When 
she  heard  the  word  pain,  she  said,  "Who  says  paint,  Pauline  used 
paint,  I  used  paint,"  etc. 


SUICIDAL  CASES  65 

Towards  the  end  of  August  she  had  pneumonia,  which  did  not 
change  her  condition. 

By  October  she  was  well,  having  gradually  settled  down.  She 
had  good  insight. 

Betrospectively :  She  laid  very  little  stress  on  the  false  report 
of  the  father's  death.  She  claimed  to  remember  being  at  the 
Observation  Pavilion,  but  to  recall  very  little  of  the  other  hos- 
pital. Unfortunately  an  inquiry  was  not  made  regarding  her 
memory  during  the  stupor  period  under  observation  with  the  ex- 
ception of  the  fact  that  she  said  she  wanted  to  die  and  therefore 
refused  food. 

She  was  seen  in  March,  1913,  appeared  perfectly  well,  and 
stated  she  had  been  well  during. the  entire  interval. 

If  this  forced  holding  of  the  breath  had  been  the 
only  anomaly,  one  would,  perhaps,  not  be  justified 
in  drawing  any  conclusions  as  to  its  significance. 
But  the  deep  stupor  was  interrupted  again  for  a  day 
by  grunting  and  screaming  of  ^* murder."  This  is 
certainly  indicative  of  a  compulsive  death  idea  and 
retrospectively  she  spoke  of  having  refused  food  in 
order  to  die.  The  latter  seems  to  indicate  some 
connection  between  her  negativism  and  death.  Con- 
sequently, even  if  we  regard  the  breath  holding  as 
resistiveness,  it  would  still  be  related  to  her  idea  of 
dissolution.  Her  negativism  went  beyond  ordi- 
nary limits  in  that  it  affected  the  expression  of  the 
face. 

When  we  consider  these  three  cases  together,  we 
see  that  what  would  otherwise  have  been  deep 
stupors  with  profound  inactivity,  were  modified  by 
activity  in  two  directions:  suicidal  and  resistive. 
Presuming  that  the  symptoms  of  stupor  are  all  in- 
terrelated, we  can  see  a  reason  why  the  affect  should 


66  BENIGN  STUPORS 

also  have  been  altered.  When  one  is  modified,  this 
should  influence  the  other.  When  the  activity  is 
increased,  the  emotional  concomitants  of  impulsive 
acts  tend  to  break  through  as  well.  Hence  the 
changes  observed  in  these  cases  in  facial  expression 
and  tone  of  voice.  It  is  noteworthy,  too,  that  all 
three  showed  a  tendency  for  laughter  to  appear,  as 
if,  the  emotions  once  stirred,  it  was  possible  for 
them  to  be  exhibited  in  other  than  unpleasant  forms. 
So,  too,  it  was  possible  for  ideas  unrelated  to  the 
stupor  picture,  such  as  those  of  lovers,  to  occur 
sporadically.  Finally,  since  activity  must  imply 
some  contact  with  environment,  the  first  of  these 
cases  at  least  showed  less  interference  with  the  in- 
telligence than  is  usual.  In  general,  one  may  con- 
clude that  any  aberration  from  the  pure  type  of 
stupor  tends  to  allow  other  impurities  to  appear. 


CHAPTER  IV 

THE  INTERFERENCES  WITH  THE  INTELLECTUAL 

PROCESSES 

This  is  one  of  the  most  interesting  and  important 
of  the  stupor  symptoms.  We  are  accustomed  to 
think  of  the  functional  psychoses  having  symptoms 
to  do  with  emotions  and  ideas  in  the  main,  and, 
conversely,  that  disorientation,  etc.,  observed  in  such 
cases  is  merely  the  result  of  distraction,  poor  atten- 
tion or  cooperation.  But  in  stupor  the  deficit  in 
understanding,  incapacity  to  solve  simple  problems 
and  failure  of  memory  seem  deep-rooted  and  funda- 
mental symptoms.  So  far  is  this  true  that  Bleuler  * 
looks  on  '^schizophrenic''  cases  with  this  symptom 
of  ^^Benommenheit"  as  organic  in  etiology.  It  may 
be  said  at  the  outset  that  we  do  not  share  this  view 
for  many  reasons.  One  at  least  may  now  be  stated 
as  it  seems  to  be  final.  In  benign  stupor  purely 
mental  stimuli  may  change  the  whole  clinical  picture 
abruptly  and  with  this  produce  a  change  in  the  intel- 
lectual functioning  such  as  we  never  see  in  organic 
dementias  or  clouded  states.  We  find  it  more  satis- 
factory to  attempt  a  correlation  of  this  with  the 
other  symptoms  on  a  purely  functional  basis,  as  wil^ 
be  explained  later. 

^See  Chapter  XV. 

67 


68  BENIGN  STUPORS 

For  the  study  of  the  interferences  with  the  intel- 
lectual processes  during  stupor  reaction,  we  have 
two  sources  of  information:  The  first  is  derived 
from  the  account  which  the  patient  is  able  to  give  in 
regard  to  what  he  remembers  as  having  taken  place 
around  him  or  in  his  mind  during  the  stupor  period ; 
the  second  is  the  direct  observation  of  partial  stupor 
reactions. 

I.     Information  Derived  from  the  Patient's  Retrospective 

Account 

We  will  start  with  the  cases  of  marked  stupor  men- 
tioned in  Chapter  I.  Anna  Gr/s  (Case  1)  psychosis 
commenced  at  home,  and  under  observation  lasted 
with  great  intensity  for  five  months.  She  remem- 
bered only  vaguely  the  carriage  going  to  the  Ob- 
servation Pavilion,  had  no  recollection  of  the  latter, 
nor  of  her  transfer  to  the  Manhattan  State  Hospital 
and  of  most  of  the  stay  at  the  Institute  ward,  includ- 
ing the  tube-  or  spoon-feeding  which  had  to  be 
carried  on  for  four  months.  She  also  claimed  that 
she  did  not  know  where  she  was  until  four  or  five 
months  after  admission.  She  was  amnesic  for  her 
delusions  and  hallucinations.  Of  Caroline  DeS. 
(Case  2)  we  have  no  information.  Of  Mary  F. 
(Case  3),  whose  stupor  began  at  home  and  under 
observation  lasted  two  years,  we  find  that  she  had 
no  recollection  of  coming  to  the  hospital,  what  ward 
she  came  to,  who  the  doctor  and  nurses  were  (with 
whom  she  became  acquainted  later),   in  fact  she 


WITH  THE  INTELLECTUAL  PROCESSES      69 

claimed  that  for  about  a  year  she  ad  not  know 
where  she  was.  But  she  remembered  .laving  been 
tube-fed  (this  took  place  over  a  long  peri  ^d).  Mary 
D.'s  (Case  4)  stupor  also  commenced  at  ^  ome,  and 
under  observation  lasted  for  three  months.  She  had 
no  recollection  of  going  to  the  Observation  P.  vilion, 
of  the  transfer  to  Manhattan  State  Hospital,  i<^d  of 
a  considerable  part  of  her  stay  here,  including  Luch 
obtrusive  facts  as  a  presentation  before  a  staff  mev  t- 
ing,  an  extensive  physical  and  a  blood  examination 
and  she  claimed  not  to  have  known  for  a  long  time 
where  she  was.  Annie  K.'s  (Case  5)  stupor  com- 
menced at  home.  Although  she  recalled  the  last 
days  there  and  some  ideas  and  events  at  the  Obser- 
vation Pavilion,  the  memory  of  the  journey  to 
Ward^s  Island  was  vague,  as  was  that  of  entrance 
to  the  ward,  and  she  claimed  not  to  have  known 
where  she  was  for  quite  a  while.  Specific  occur- 
rences, such  as  the  taking  of  her  picture  (with  open 
eyes  two  months  after  admission),  an  examination 
in  a  special  room,  her  own  mixed-up  writing  (end  of 
second  week)  were  not  remembered.  But  it  is  quite 
interesting  that  an  angry  outburst  of  another  pa- 
tient within  this  same  period,  which  was  evidently 
not  recorded,  is  clearly  remembered. 

We  shall  later  show  that  when  the  patient  comes 
out  of  a  stupor  the  condition  may  be  such  that,  for 
a  time  at  least,  retrospective  accounts  are  difficult 
to  obtain.  It  must  also  be  remembered  that  not  in- 
frequently the  more  marked  stupors  may  be  fol- 
lowed by  milder  states,  and  it  is  important,  if  we 


70  BENIGN  STUPORS 

wish  to  detenoine  how  much  is  remembered,  not  to 
confuse  the  two  states  or  not  to  let  the  patient  con- 
fuse them.  For  example,  Mary  D.  (Case  4),  who 
showed  two  separate  phases,  while  she  claimed  not 
to  know  of  many  external  facts,  also  added  that  she 
could  not  understand  the  questions  which  were 
asked.  From  observation  in  other  cases  it  seems 
that  in  marked  stupor  any  such  recollection  about 
the  patient's  own  mental  processes  would  be  quite 
inconsistent.  We  have  to  assume,  therefore,  that  this 
remark  referred  in  reality  to  the  second  milder 
phase,  for  which,  as  we  shall  see,  it  is  indeed  quite 
characteristic.  It  is  not  necessary  to  burden  the 
reader  with  other  cases,  all  of  which  consistently 
gave  such  accounts. 

We  see,  then,  that  in  the  marked  stupor  the  intel- 
lectual processes  are  regularly  interfered  with,  as 
evidenced  by  almost  complete  amnesia  for  external 
events  and  internal  thoughts.  In  other  words,  this 
would  indicate  that  the  minds  of  these  patients  were 
blank.  Inasmuch  as  direct  observation  during  the 
stupor  adduces  little  proof  of  mentation,  we  may 
assume  that  such  mental  processes  as  may  exist  in 
deepest  stupor  are  of  a  primitive,  larval  order. 

Before  we  examine  more  carefully  the  milder 
grades  of  stupor,  it  will  be  necessary  to  say  a  few 
words  about  the  retrospective  account  which  the 
patient  gives  of  intellectual  difficulties  during  the 
incubation  period  of  the  psychosis.  As  a  matter  of 
fact,  we  find  that  these  accounts  are  remarkably 
uniform.    While  some  patients,  to  be  sure,  speak  of 


WITH  THE  INTELLECTUAL  PROCESSES      71 

a  more  or  less  sudden  lack  of  interest  or  ambition 
which  came  over  them,  others  of  them  speak  plainly 
of  a  sudden  mental  loss.  Mary  C.  (Case  7)  claimed 
she  suddenly  got  mixed  up  and  lost  her  memory. 
Laura  A.  spoke  at  any  rate  of  suddenly  having  felt 
dazed  and  stunned.  Mary  D.  (Case  4)  said  she  felt 
she  was  losing  her  mind  and  that  she  could  not  un- 
derstand what  she  was  reading.  Maggie  H.  (Case 
14)  began  to  say  that  her  head  was  getting  queer. 
We  see  from  this  that  the  interferences  with  the  in- 
tellectual processes  may  in  the  beginning  be  quite 
sudden. 

In  some  instances  a  more  detailed  retrospective 
account  was  taken,  which  may  throw  some  light  upon 
the  interferences  with  the  intellectual  processes  with 
which  we  are  now  concerned.  Emma  K.,  whose  case 
need  not  be  taken  up  in  detail,  had  a  typical  marked 
stupor  which  lasted  for  nine  months,  preceded  by  a 
bewildered,  restless,  resistive  state  for  five  days. 
She  was  in  the  Institute  ward  for  the  first  four 
months,  including  the  ^ve  days  above  mentioned; 
later  in  another  ward.  When  asked  what  was  the 
first  ward  which  she  remembered,  she  mentioned  the 
one  after  the  Institute  ward,  and  when  asked  who 
the  first  physician  was,  she  mentioned  the  one  in 
charge  of  the  second  ward.  However,  when  taken 
to  the  Institute  ward,  she  said  it  looked  familiar,  and 
was  able  to  point  to  the  bed  in  which  she  lay,  though 
somewhat  tentatively.  The  same  rousing  of  memory 
occurred  when  the  first  physician,  who  saw  her  daily, 
was  pointed  out  to  her.     She  remembered  having 


72  BENIGN  STUPORS 

seen  him,  and  then  even  recalled  the  fact  that  he  had 
thrown  a  light  into  her  eyes,  but  remembered  noth- 
ing else.  This  observation  would  seem  to  show  that 
with  some  often  repeated  or  very  marked  mental 
stimuli  (throwing  electric  light  into  her  eyes)  a 
vague  impression  may  be  left,  so  that  it  may  at  least 
be  possible  to  bring  about  a  recollection  with  as- 
sistance, whereas  spontaneous  memory  is  impos- 
sible. In  another  instance,  the  patient  was  con- 
fronted with  a  physician  who  had  seen  a  good  deal 
of  her.  She  said  that  he  looked  familiar  to  her,  but 
she  was  unable  to  say  where  she  had  seen  him.  Here 
then  again  evidence  that  a  certain  vague  impression 
was  made  by  a  repeated  stimulus. 

Another  feature  should  here  be  mentioned, 
namely,  that  isolated  facts  may  be  remembered 
when  the  rest  is  blank.  We  have  seen  above 
that  Annie  K.  (Case  5),  while  very  vague  about 
most  occurrences,  recalled  a  sudden  angry  outburst 
in  detail.  Another  patient,  though  the  period  of  the 
stupor  was  a  blank,  recalled  some  visits  of  her 
mother.  At  these  times,  as  she  claimed,  she  thought 
she  was  to  be  electrocuted  and  told  her  mother  so, 
^  *  Then  it  would  drop  out  of  my  mind  again. "  These 
facts  are  very  interesting.  We  can  scarcely  account 
for  such  phenomena  in  any  other  way  than  by  assum- 
ing that  certain  influences  may  temporarily  lift  the 
patient  out  of  the  deepest  stupor.  In  spite  of  the  fact 
that  stupors  often  last  for  one  or  two  years  almost 
without  change,  a  fact  which  would  argue  that  the 
stupor  reaction  is  a  remarkably  set,  stable  state, 


WITH  THE  INTELLECTUAL  PROCESSES      73 

we  see  in  sudden  episodes  of  elation  that  this  is  not 
the  case,  and  other  experiences  point  in  the  same  di- 
rection. A  similar  observation  was  made  on  a  case  of 
typical  stupor  with  marked  reduction  of  activity  and 
dullness.  A  rather  cumbersome  electrical  apparatus 

(for  the  purpose  of  getting  a  good  light  for  pupil 
examination)  was  brought  to  her  bedside.  Whereas 
before,  she  had  been  totally  unresponsive,  she  sud- 
denly wakened  up,  asked  whether  "those  things" 
would  blow  up  the  place,  and  whether  she  was  to  be 
electrocuted.  During  this  anxious  state  she  re- 
sponded promptly  to  commands,  but  after  a  short 
time  relapsed  into  her  totally  inactive  condition. 
We  have,  of  course,  similar  experiences  when  we  try 
to  get  stuporous  patients  to  eat,  who,  after  much 
coaxing  may,  for  a  short  time,  be  made  to  feed  them- 
selves, only  to  relapse  into  the  state  of  inactivity. 

"^Such  variations  are  paralleled,  as  we  shall  later 
show,  by  a  suddenly  pronounced  deepening  of  the 
thinking  disorder.  We  have  already  seen  that  the 
onset  may  be  quite  sudden.  All  this  indicates  that, 
in  spite  of  a  certain  stability,  sudden  changes  are 
not  uncommon.  Finally,  we  know  that,  in  spite  of 
the  fact  that  stupor  is  an  essentially  affectless  reac- 
tion, certain  influences  may  produce  smiles  or  tears, 
or,  above  all,  angry  outbursts,  which  again  can 
hardly  be  interpreted  otherwise  than  by  assuming 
that  those  influences  have  temporarily  produced  a 
change  in  the  clinical  picture,  in  the  sense  of  lifting 
the  patient  out  of  the  depth  of  the  stupor.    All  these 


74  BENIGN  STUPORS 

facts  suggest  that  inoonsistencies  in  recollection  are 
correlated  with  changes  in  the  clinical  picture. 

As  is  to  be  expected,  the  cases  with  partial  stupors 
remember  much  more  of  what  externally  and  inter- 
nally happened  during  their  psychoses.  Rose  Sch. 
(Case  6),  who  had  a  partial  stupor  during  which  she 
answered  questions  but  showed  a  great  difficulty  in 
thinking,  said  retrospectively  that  she  felt  mixed  up 
and  could  not  remember.  Although  she  recalled 
with  details  the  Observation  Pavilion  and  her  trans- 
fer, she  was  not  clear  about  their  time  relations 
(how  long  in  the  Observation  Pavilion,  how  long  in 
the  first  ward).  Mary  C.  (Case  7),  whose  activity 
was  not  entirely  interfered  with  and  who  showed 
some  thinking  disorder,  said  retrospectively  that  she 
could  not  take  in  things.  Henrietta  H.  (Case  8),  who 
had  a  partial  stupor,  claimed  to  have  known  all 
along  where  she  was,  but  that  she  felt  mixed  up, 
that  her  thoughts  wandered  and  that  she  felt  con- 
fused about  people.  In  the  cases  where  a  partial 
stupor  was  preceded  by  a  marked  one,  such  as  in 
phase  2  of  Anna  G.  (Case  1)  and  phase  2  of  Mary 
D.  (Case  4),  we  have  no  retrospective  account  re- 
garding the  partial  stupor,  because  emphasis  in  the 
analysis  was  naturally  laid  on  the  period  comprising 
the  most  marked  disorder.  However,  we  can  gather 
from  the  few  cases  at  our  disposal  that  the  patients 
retrospectively  lay  stress  chiefly  on  their  inability 
to  understand  the  situation. 

We  finally  have  to  consider  the  group  of  suicidal 
cases.    We  have  information  only  in  regard  to  two 


WITH  THE  INTELLECTUAL  PROCESSES      75 

cases,  namely,  Margaret  C.  (Case  10)  and  Pearl  F. 
(Case  9) .  In  both  of  these,  we  find  that  a  good  many 
things  that  happened  during  the  period  under  con- 
sideration were  remembered,  as  were  also  the 
patients'  own  actions.  In  Eosie  K.  (Case  11)  we 
have  at  least  the  evidence  that  she  remembered  her 
own  impulses,  namely,  that  she  refused  food  because 
she  wanted  to  die.  In  other  words,  in  these  partial 
stupors  with  impulsive  suicidal  tendencies  the  inter- 
ference with  the  intellectual  processes  seems  to  be 
moderate,  and  memory  for  external  events  not 
markedly  affected. 

2.     Information  Derived  from  Direct  Observation 

The  evidence  can  best  be  presented  by  considering 
the  details  of  some  cases. 

Eose  Sch.  (Case  6)  was  remarkable,  in  connection 
with  the  present  problem,  in  her  unusually  poor 
answers.  She  either  merely  repeated  the  questions, 
or  made  irrelevant  superficial  replies,  or  said  she  did 
not  know,  this  even  with  very  simple  questions. 
When  better,  too,  though  not  quite  well,  she  showed 
striking  discrepancies  in  time  relations  and  incapac- 
ity to  correct  them.  It  would  seem  that  in  this  case 
there  was  something  more  than  an  acute  interfer- 
ence with  the  intellectual  processes,  such  as  we  are 
here  discussing.  As  a  matter  of  fact,  we  have  the 
statement  in  the  history  that  the  patient  herself  said 
she  was  slow  at  learning  in  school  and  had  not  much 
of  an  education.     A  congenital  intellectual  defect 


76  BENIGN  fe'^TipORS 

and  the  attitude  which  it  creates  may,  however,  as 
my  experience  has  repeatedly  shown  me,  very 
greatly  exaggerate  an  acute  thinking  disorder.  The 
case,  therefore,  while  it  shows  us  an  unquestionably 
acute  interference  with  the  intellectual  processes, 
does  not  give  us  useful  information  about  its  nature. 
More  information  can  be  gathered  from  Mary  D. 
(Case  4).  Even  toward  the  end  of  her  marked 
stupor  some  replies  were  obtained  chiefly  by  making 
her  write.  When  asked  to  write  Manhattan  State 
Hospital,  she  wrote  Manhatt  Hhospshosh,  and  for 
Ward 's  Island,  Ww.  Iland.  Again,  instead  of  writ- 
ing 90th  Street,  she  wrote  90theath  Street.  These 
are  plainly  reactions  of  the  path  of  least  resistance 
or,  in  these  instances,  of  perseveration.  Of  the 
same  nature  are  some  of  her  other  replies  in  writing 
or  speaking.  After  she  had  been  asked  to  write  her 
name,  she  was  requested  to  add  her  address,  or  the 
name  of  the  hospital ;  she  merely  repeated  the  name. 
Similarly,  when  asked  whether  she  knew  the  ex- 
aminer, she  said  ^^Yes,''  but  when  urged  to  give  his 
name,  she  gave  her  own.  In  the  partial  stupor  at  a 
time  when  she  knew  where  she  was,  knew  the  names 
of  some  people  about  her,  the  year  and  approxi- 
mately the  date,  she  made  mistakes  in  calculation  and 
could  not  get  the  point  of  a  test  story.  Moreover, 
she  failed  in  retention  tests  without  there  being  any 
evidence  of  anything  like  a  marked  fundamental 
retention  disorder,  such  as  we  find  in  Korsakoff 
psychosis.  It  seems  that  these  results  are  best 
termed  defects  in  attention,  which  chiefly  interfere 


WITH  THE  INTELLECTUAL  PROCESSES      77 

with  the  apprehension  of  more  difficult  tasks.  As 
we  shall  see  later,  this  seems  to  be  rather  character- 
istic of  these  cases.  Another  point  which  should  be 
mentioned  is  the  fact  that  her  reaction  to  questions 
which  she  was  unable  to  answer  (such  as  matters 
which  referred  to  her  amnesic  periods)  was  peculiar, 
inasmuch  as  she  did  not  only  not  try  to  think  them 
out,  but  seemed  indifferent  to  her  incapacity,  simply 
leaving  the  question  unanswered.  This  too,  as  we 
shall  see  later,  is  characteristic.  Laura  A.,  at  a  time 
when  she  could  be  made  to  reply,  merely  repeated 
the  question,  again  a  reaction  of  least  resistance. 
The  same  patient  sometimes  asked,  ** Where  am  IV ^ 
Mary  C.  (Case  7)  made  similar  queries.  Although 
she  was  at  times  approximately  oriented,  she  would 
say,  **I  don't  know  where  I  am,'*  or  **I  can't  realize 
where  I  am,"  or  more  pointedly,  *'I  can't  take  in  my 
surroundings. "  She  often  did  not  answer  and  some- 
times seemed  bewildered  by  the  questions.  Henri- 
etta H.  (Case  8)  again  showed  some  defect  of 
orientation  and  mistakes  in  calculation,  and  above 
all,  marked  mistakes  in  writing  (for  Manhattan 
State  Hospital — Manhaton  Hotspal) .  A  special  fea- 
ture here  is  that  this  occurred  immediately  after  she 
had  been  quite  talkative,  but  suddenly  had  relapsed 
into  a  dull  state.  Anna  G.  (Case  1),  during  the  third 
phase  of  her  psychosis,  showed  the  following:  Al- 
though she  was  approximately  oriented  and  an- 
swered promptly  simple  questions;  e.g.,  about 
orientation  or  simple  calculation,  she,  like  these 
other  patients,  simply  remained  silent  when  more 


78  BENIGN  STUPORS 

difficult  intellectual  tasks  were  required  of  her  (more 
difficult  calculations) ;  or  when  she  was  asked  how 
long  she  had  been  here  (which  involved  data  that 
could  not  be  available  to  her,  owing"  to  her  amnesia) ; 
or  when  questions  were  put  to  her  regarding  her 
feelings  or  the  condition  she  had  passed  through. 
On  the  other  hand,  she  sometimes  gave  appropriate 
replies  in  the  words  ^'yes"  or  *'no,''  but  it  was 
difficult  to  say  whether  these  answers  did  not  also 
represent  the  path  of  least  resistance. 

We  will  finally  take  up  the  last  phase  of  Margaret 
C.  (Case  10).  Although  she  was  entirely  oriented, 
there  was  a  certain  vagueness  about  her  answers 
which  is  difficult  to  formulate.  She  was  telling  about 
the  onset  of  her  sickness  and  said  that  at  that  time 
her  mind  was  taken  up  with  prayers  about  the  salva- 
tion of  her  relatives.  She  was  asked  exactly  when 
it  was  that  she  thought  of  this  and  she  answered 
**Nowr'  (What  period  are  we  talking  about?) 
**The  present.''  (What  did  I  ask  you?)  ^^About 
this  period  of  my  sickness.''  (Which  one?)  **What 
sickness?"  She  said  herself  at  this  point,  *'I  am 
rather  stupid."  Again  when  asked  how  her  mind 
worked,  she  said,  **  Pretty  quickly  sometimes — ^I 
don't  know."  (As  good  as  it  used  to?)  ^^ISTo,  I 
don't  think  so. ' '  (What  is  the  difference ?)  ' ' There 
is  no  difference. ' '  (What  did  I  ask  you  ? )  '  *  The  dif- 
ference." (The  difference  between  what?)  **You 
did  not  say."  In  this  the  shallowness  of  her  compre- 
hension and  thinking  is  well  shown,  and  it  seems 
here  again  perhaps  justifiable  to  formulate  the  main 


WITH  THE  INTELLECTUAL  PROCESSES      79 

defect  as  one  of  attention,  which  prevents  comple- 
tion of  a  complicated  process  of  comprehension.  A 
feature  of  further  interest  in  this  case  is  that  auto- 
matic intellectual  processes,  such  as  those  necessary 
for  the  writing  of  a  long  poem  from  memory,  were 
not  interfered  with. 

Summary 

In  the  most  pronounced  stupor  we  have  evidently 
a  more  or  less  complete  standstill  in  thinking 
processes.  Practically  no  impressions  are  regis- 
tered and  consequently  nothing  is  remembered  ex- 
cept events  that  occurred  in  some  short  periods 
when  some  affective  stimulus,  or  a  brief  burst  of 
elation,  lifts  the  patient  temporarily  out  of  the  deep 
stupor.  It  is  impossible  to  say  whether  the  state- 
ment of  a  complete  standstill  has  to  be  qualified.  In 
some  stupors  repeated  environmental  stimuli  some- 
times make  at  least  a  vague  impression,  so  that  while 
spontaneous  recollection  is  impossible  a  feeling  of 
familiarity  is  present  when  the  patient  is  again  con- 
fronted with  this  environment.  This  might  be  an 
exception  to  the  dictum  of  complete  mental  vacuity, 
or  it  may  be  that  there  are  somewhat  less  pro- 
nounced stupor  reactions.  When  more  is  perceived, 
there  is  often  a  retrospective  statement  of  having 
felt  mixed  up,  being  unable  to  take  in  things,  or, 
directly  under  observation,  the  patient  may  say,  *^I 
cannot  realize  where  I  am,*'  *'I  cannot  take  in  my 
surroundings.''  In  harmony  with  this  is  the  fact 
that  questions  often  produce  a  certain  bewilderment. 


80  BENIGN  STUPOKS 

In  quite  pronounced  states  in  which  some  replies 
can  still  be  obtained,  we  find  that  the  intellectual 
processes  may  be  interfered  with  to  the  extent  of  a 
paragraphia,  i.e.,  a  remarkably  mixed-up  writing  in 
which  perseveration  (one  form  of  following  the  path 
of  least  resistance)  plays  a  prominent  part.  This 
same  principle  is  also  seen  in  such  reactions  as  the 
repetition  of  the  question  or  the  senseless  repetition 
of  a  former  answer.  These  phenomena  remind  us 
of  what  we  see  in  epileptic  confusions,  in  epileptic 
deterioration  and  in  arteriosclerotic  dementia. 

In  milder  cases  difficulties  in  orientation  may  be 
more  or  less  marked ;  or  there  may  be  incapacity  to 
think  out  problems,  although  the  orientation  is  per- 
fect. The  more  automatic  mental  processes  may 
run  smoothly  (memory  and  calculation  may  be  ex- 
cellent) and  there  may  yet  be  a  certain  shallowness 
in  thinking,  a  defect  of  attention  (a  purely  descrip- 
tive term)  which  is  most  obvious  in  the  patient's 
inability  to  grasp  clearly  the  drift  of  what  is  going 
on  or  the  meaning  of  complicated  questions.  I  am 
inclined  to  think  that  poor  results  in  retention  tests 
are  entirely  due  to  this  attention  disorder,  for  we 
have  no  evidence  of  any  fundamental  retention  de- 
fect such  as  we  find  in  the  totally  diif  erent  organic 
stupors.  From  a  practical  point  of  view  it  is  im- 
portant at  this  place  to  call  attention  to  the  fact 
that  such  mild  changes  are  particularly  seen  in  end 
stages.  Even  when  pronounced  negativistic  ten- 
dencies do  not  play  a  prominent  role,  the  patient  is 
then  apt  to  be  silent  chiefly  as  a  result  of  the  residual 


WITH  THE  INTELLECTUAL  PROCESSES      81 

disorder  in  the  intellectual  processes.  Still  more 
striking  are  the  conditions  which  are  on  a  somewhat 
higher  level  and  in  which  the  shallowness  of  the  re- 
sponses, due  to  the  residual  disorder  of  attention, 
together  with  the  last  traces  of  the  affectlessness, 
are  apt  to  create  the  impression  of  a  dementia.  In 
such  cases  the  opinion  is  often  held  that  the  patient 
has  reached  a  defect  stage  from  which  recovery  is 
impossible,  whereas  a  thorough  knowledge  of  these 
end  stages  teaches  us  that  they  are  not  only  recov- 
erable but  quite  typical  for  the  terminal  phases  of 
stupor. 

Considering  these  data,  especially  those  gathered 
in  the  end  stages,  it  would  appear  that  there  is  no 
tendency  in  this  intellectual  disorder  associated  with 
the  stupor  reaction  for  any  special  side  of  mental 
activity  to  be  most  prominently  affected.  It  looks 
rather  as  if  it  were  a  question  of  a  general  diminu- 
tion of  the  capacity  to  make  a  mental  effort  which  in 
its  different  intensities  accounts  for  the  symptoms. 


CHAPTER  V 
THE  IDEATIONAL  CONTENT  OF  THE  STUPOR 

Brief  survey  of  the  ideas  associated  with  stupor: 
Having  thus  described  the  formal  manifestations  of 
the  various  stupor  reactions,  it  will  now  be  inter- 
esting to  see  what  ideas  seem  to  be  associated  with 
these  reactions.  It  is,  of  course,  impossible  to  obtain 
during  a  considerable  part  of  the  stupor  any  state- 
ment of  the  patients'  thoughts.  We  therefore  have 
to  depend  on  their  utterances  during  periods  when 
the  inactivity  temporarily  ceases,  or  on  the  retro- 
spective account  which  the  patient  gives  after  the 
stupor  has  completely  disappeared ;  and  as  we  shall 
see,  we  also  may  obtain  considerable  information  by 
studying  the  ideas  which  occur  in  the  period  pre- 
ceding the  stupor.  These  last  may  be  autogenous 
delusions  or  thoughts  about  actual  events  which  pre- 
cipitated the  psychosis. 

It  is  not  likely  that  many  observers  have  a  very 
clear  conception  about  what  sort  of  ideas  to  expect. 
We  have,  as  a  rule,  not  been  in  the  habit  of  paying 
much  attention  to  the  content  of  delusions,  halluci- 
nations, and  the  like.  So  far  as  we  could  judge, 
therefore,  the  ideas  expressed  might  be  expected  to 
be  fairly  multiform,  and  it  was  distinctly  interesting 

82 


IDEATIONAL   CONTENT  OF  THE  STUPOR      83 

to  us  when  we  found  a  marked  tendency  for  the 
trends  of  ideas  to  remain  within  a  certain  small 
compass.^  It  was  possible,  to  state  this  at  once,  to 
show  that  in  by  far  the  majority  of  cases  the  same 
set  of  ideas  returned,  and  that  these  ideas  had 
among  themselves  a  definite  inner  relationship,  be- 
ing concerned  with  thoughts  of  ''death."  In  iso- 
lated instances  other  ideas  were  found  as  well,  and 
they  will  have  to  be  discussed  later.  For  the  present 
we  shall  take  up  more  habitual  content. 

In  addition  to  the  eleven  cases  already  described, 
it  may  be  well  to  cite  four  others  which  present 
material  now  of  interest  to  us. 

Case  12. — Charlotte  W.  Age:  30.  Admitted  to  the  Psychi- 
atric Institute  October  21,  1905. 

F.  H,  The  father  was  alcoholic  and  quick-tempered;  he  died 
when  the  patient  was  a  child.  The  mother  was  alcoholic  and 
was  insane  at  40  (a  state  of  excitement  from  which  she  recov- 
ered). A  brother  had  an  attack  of  insanity  in  1915.  A  maternal 
uncle  died  insane. 

P.  H.  The  patient  was  described  as  jolly,  having  many  friends. 
She  got  on  well  in  school  and  was  efficient  at  her  work. 

She  was  married  at  23  and  got  on  well  with  her  husband. 
The  latter  stated,  however,  that  she  masturbated  during  the  first 
year  of  her  married  life.  The  first  child  was  born  without 
trouble. 

First  Attack  at  25:  Two  or  three  days  after  giving  birth  to 
a  second  child,  her  mother  burst  into  the  room  intoxicated.  The 
patient  immediately  became  much  frightened,  nervous,  and  devel- 
oped a  depressive  condition  with  crying,  slowness  and  inability 
to  do  things.     During  this  state  she  spoke  of  being  bad  and  told 

^  Kirby,  loc  cit.,  pointed  out  that  stupor  showed  resemblance  to 
feigned  death  in  animals,  that  the  reaction  suggested  a  shrinking 
from  life  and  that  ideas  of  death  were  common. 


84  BENIGN  STUPORS 

her  husband  that  a  man  had  tried  to  have  intercourse  with  her 
before  marriage.  This  attack  lasted  six  months  and  ended  with 
recovery. 

When  29,  a  year  before  her  admission,  she  had  an  abortion 
performed,  and  four  months  later  another.  Her  husband  was 
against  this,  but  she  persisted  in  her  intention.  Seven  months 
before  admission  she  went  to  the  priest,  confessed  and  was  re- 
proved. It  is  not  clear  how  she  took  this  reproof,  but  at  any 
rate  no  symptoms  appeared  until  three  weeks  later,  after  bur- 
glars had  broken  into  a  nearby  church.  Then  she  became  unduly 
frightened,  would  not  stay  at  home,  said  she  was  afraid  the  bur- 
glars would  come  again  and  kill  "some  one  in  the  house."  The 
patient  herself  stated  later,  during  a  faultfinding  period,  that 
at  that  time  she  was  afraid  somebody  would  take  her  honor  away, 
and  that  she  thought  burglars  had  taken  her  "wedding  dress." 
"Then,"  she  added,  "I  thought  I  would  run  away  and  lead  a  bad 
life,  but  I  did  not  want  to  bring  disgxace  to  the  family." 

The  general  condition  which  she  presented  at  thir  lime  is  de- 
scribed as  one  of  apprehensiveness  when  at  horn  .  For  thi 
reason  she  was  for  five  weeks  (it  is  not  clear  exactly  at  wh  t 
period)  sent  to  her  sister,  where  she  was  better.  About  a  mo)  ch 
before  the  patient  was  admitted,  the  husband  moved,  whereu  /on 
she  got  depressed,  complained  of  inability  to  apply  herse^  .  to 
work,  became  slow  and  inactive,  and  blamed  rself  for  h  ving 
had  the  abortion  performed.  She  began  to  sf  :  k  of  suicir  3  and 
was  committed  because  she  bought  carbolic  acid.  She  lat  r  said 
that  while  in  the  Observation  Pavilion  she  imagined  her  nildren 
were  cut  up. 

Under  Observation  the  condition  was  as  follows: 

1.  For  the  first  three  days  the  patient,  though  for  the 'most 
part  not  showing  any  marked  mood  reaction,  was  "  iclined  at 
times  to  cry,  and  at  such  times  complained  essenti'^F/  (hat  this 
was  a  terrible  place  for  a  person  who  was  not  ins. 

2.  On  the  fourth  day  the  condition  changed,  a?  i  it  will  be 
advisable  to  describe  her  state  in  the  form  of  abs  -acts  of  each 
day. 

On  October  24  the  patient  began  to  be  preo  3upied  and  to 
answer  slowly.  A  few  days  later  she  became  distinctly  dull, 
walked   about   in   an  indifferent   way   or   lay   i  .  bed   immobile. 


IDEATIONAL   CONTENT  OF  THE  STUPOR      85 

Twice  on  October  27  she  said  in  a  low  tone  and  with  slight  dis- 
.  tress,  "Give  me  one  more  chance,  let  me  go  to  him."  But  she 
would  not  answer  questions.  At  times  she  lapsed  into  complete 
immobility,  lying  on  her  back  and  staring  at  the  ceiling.  When 
the  husband  came  in  the  afternoon,  she  clung  to  him  and  said: 
"Say  good-by  forever,  0  my  God,  save  me."  Again,  very  slowly 
with  long  pauses  and  with  moaning,  she  said:  "You  are  going 
to  put  me  in  a  big  hole  where  I  will  stay  for  the  rest  of  my  life." 
On  October  28  she  was  found  with  depressed  expression  and 
spoke  in  a  rather  low  tone,  but  not  with  decided  slowness  as  had 
been  the  case  on  the  day  before.  She  pleaded  about  having  her 
soul  saved;  "Don't  kill  me";  "Make  me  true  to  my  husband"; 
once,  "I  have  confessed  to  the  wrong  man  the  shame  of  my  life." 
Later  she  said  she  did  not  tell  the  truth  about  her  life  before 
marriage.  Again  she  wanted  to  be  saved  from  the  electric  chair. 
At  times  she  showed  a  tendency  to  stare  into  space  and  to  leave 
questions  unanswered. 

3.  From  now  on  a  more  definite  stupor  occurred,  which  is  also 
best  described  in  summaries  of  the  individual  notes. 

Oct.  29.  Lies  in  bed  with  fixed  gaze,  pointing  upward  with 
her  finger  and  is  very  resistive  towards  any  interference.  She 
has  to  be  eatheterized. 

Oct.  30.  Can  be  spoon-fed  but  is  still  eatheterized.  During 
the  morning  she  knelt  by  the  bed  and  would  not  answer.  At  the 
visit  she  was  found  in  a  rather  natural  position,  smiling  as  the 
physician  approached,  saying  "I  don't  know  how  long  I  have  been 
here."  Then  she  looked  out  of  the  window  fixedly.  At  first 
she  did  not  answer,  but,  when  the  physician  asked  whether  she 
knew  his  name,  she  laughed  and  said,  "I  know  your  name — I  know 
my  name."  Then  she  would  not  answer  any  more  questions  but 
remained  immobile,  with  fixed  gaze.  When  her  going  home  was 
mentioned,  however,  she  flushed  and  tears  ran  down  her  cheek, 
though  no  change  in  the  fixedness  of  her  attitude  or  in  her  facial 
expression  was  seen. 

Nov.  1.  Lies  flat  on  her  back  with  her  hands  elevated.  She 
is  markedly  resistive. 

Nov.  2.  Free  from  muscular  tension  and  more  responsive. 
When  asked  whether  she  felt  like  talking,  she  said  in  a  whining 
tone,  "No,  go  away — I  have  to  go  through  enough."     Then  she 


86  BENIGN  STUPORS 

spoke  of  not  knowing  how  long  the  nights  and  days  were,  of  not 
having  known  which  way  she  was  going.  When  asked  who  the 
physician  was  she  whimpered  and  said,  "You  came  to  tell  me 
what  was  right."  She  called  him  "Christ"  and  another  physician 
"Jim"  (husband's  name),  though,  later  in  the  interview,  she 
gave  their  correct  names.  When  asked  about  the  name  of  an- 
other physician,  she  said:  "He  looks  like  my  cousin,  he  was 
here,  they  all  came  the  first  night.  I  did  not  take  notice  who 
it  was  till  I  went  through  these  spirits,  then  I  knew  it  was  right." 
— She  paused  and  added:  "My  God — mother  it  was;  she  is  here 
on  Earth,  somewhere  in  a  convent — Sister  C.  (who  actually  is  in 
a  convent)  she  was  here,  too,  I  could  hear  her."  She  said  they 
all  came  to  try  to  save  her.  When  asked  whether  she  had  been 
asleep,  she  said:  "No,  I  wasn't  asleep,  I  was  mesmerized,  but  I 
am  awake  now — sometimes  I  thought  I  was  dead."  (When?) 
"The  time  I  was  going  to  Heaven."  Again :  "I  went  to  Heaven 
in  spirit,  I  came  back  again — the  wedding  ring  kept  me  on  Earth 
— I  will  have  to  be  crucified  now."  (Tell  me  about  it.)  "Jim 
will  have  to  pick  my  eyes  out — I  think  it  is  him.  Oh,  it  is  my 
little  girl."  (Who  told  you?)  "The  spirits  told  me."  Again: 
"Little  birds  my  children — I  can't  see  them  any  more — I  must 
stay  here  till  I  die."  (Why?)  "The  spirits  told  me— till  I 
pick  every  one  of  my  eyes  out  and  my  brains  too."  When  asked 
what  day  it  was,  she  said,  "It  must  be  Good  Friday."  (Why?) 
"Because  God  told  me  I  must  die  on  the  cross  as  he  did."  When 
asked  why  she  had  not  spoken  the  day  before,  she  said  that 
"Jesus  Christ  in  Heaven"  had  told  her  she  should  not  tell  any- 
thing, "till  all  of  you  had  gone,  then  I  could  go  home  with  him, 
because  that  is  the  way  we  came  in  and  it  was  Jim  too  all  the 
time."  Finally  she  said  crossly,  "Go  away  now,  you  are  all 
trying  to  keep  me  from  Jim"   (crying). 

Nov.  3.  Knelt  by  bed  during  the  night.  This  morning  lies 
in  bed  staring,  resistive,  again  she  is  markedly  cataleptic.  She 
has  to  be  spoon-fed,  and  is  totally  unresponsive.  In  the  after- 
noon she  was  found  staring  and  resistive.  Presently  she  said 
with  tears :  "I  am  waiting  to  be  put  on  the  cross." 

Nov.  4.  Still  has  to  be  catheterized.  She  sits  up,  staring, 
with  expressionless  face,  but  when  asked  how  she  felt  she  re- 
sponded and  said  feebly:  "I  don't  know  how  I  feel  or  how  I 


IDEATIONAL   CONTENT   OF   THE   STUPOR      87 

look  or  how  long  I  have  been  here  or  anything."  (What  is 
wrong?)  "Oh,  I  only  want  to  go  to  a  convent  the  rest  of  my 
days."  (Why?)  "Oh,  I  have  only  said  wrong  things,  I  thought 
I  would  be  better  dead,  I  could  not  do  anything  right."  Later 
she  again  began  to  stare. 

Nov.  5.  During  the  night  she  is  said  to  have  been  restless  and 
wanted  to  go  to  church.  To-day  she  is  found  staring,  but  not 
resistive.  When  questioned  she  sometimes  does  not  answer.  She 
said  to  the  physician,  "I  should  have  gone  up  to  Heaven  to  you 
and  not  brought  me  down  here."  She  called  the  physician 
"Uncle  James."  Again  she  said,  "I  want  to  go  up  to  see  Jim." 
Sometimes  she  looks  indifferent,  again  somewhat  bewildered. 

Nov.  6.  She  eats  better,  catheterizing  is  no  longer  necessary. 
She  is  found  lying  in  bed,  rigid,  staring,  resistive,  does  not  an- 
swer at  first,  later  appears  somewhat  distressed,  says  "I  want  to 
go  and  see  Jim."  (Where?)  "In  Heaven."  She  gave  the  name 
of  the  place  and  of  the  physician,  also  the  date. 

Nov.  8.  In  the  forenoon,  after  she  had  presented  a  rather 
immobile  expression  and  had  answered  a  few  orientation  ques- 
tions correctly,  she  suddenly  beckoned  into  space,  then  shook 
her  fist  in  a  threatening  manner.  When  later  asked  about  this, 
she  said:  "Jim  was  down  there  and  I  wanted  to  get  him  in." 
(And?)  "You  was  up  here  first."  (And?)  "I  thought  we 
was  going  down  down,  up  up — the  boat —  — you  came  in  here 
for — to  lock  Jim  out  so  we  wouldn't  let  him  in."  Later  she  said, 
when  asked  whether  anything  worried  her,  "Yes,  you  are  taking 
Jim's  place." 

Nov.  9.  During  the  night  she  is  reported  to  have  varied  be- 
tween stiffness  with  mutism  and  a  more  relaxed  state.  Once,  the 
nurse  found  her  with  tears,  saying  "I  want  to  go  down  the  hall 
to  my  sister — to  the  river,"  and  a  short  time  later  with  fright : 
"Is  that  my  mother?"  Again  she  said:  "Oh  dear,  I  wish  this 
boat  would  stop — stop  it — where  are  we  going?"  In  the  fore- 
noon she  was  quiet  and  unresponsive.  In  the  afternoon  she  said 
in  a  somewhat  perplexed  way,  "We  were  in  a  ship  and  we  were 
'most  drowned."  (When  was  that?)  "Day  before  yesterday 
it  must  have  been" — Again  she  said  in  the  same  manner:  "It  was 
like  water.  I  was  going  down.  I  could  hear  a  lot  of  things." 
She  claimed  this  happened  "to-day."     "I  saw  all  the  people  in 


88  BENIGN  STUPOKS 

here,  it  was  all  full  of  water,"  "I  have  been  lying  here  a  long 
time — do  you  remember  the  time  I  was  under  the  ground  and  it 
seemed  full  of  water  and  every  one  got  drowned  and  a  sharp 
thing  struck  meV  "1  was  out  in  a  ship  and  I  went  down  there 
in  a  coffin."  When  asked  whether  she  had  been  frightened  at 
such  times,  she  said :  "No,  I  didn't  seem  to  be,  I  just  lay  there." 
She  also  said:  "the  water  rushed  in,"  and  when  asked  why  she 
put  up  her  arms,  she  said,  "I  did  it  to  save  the  ship." 

Nov.  10.  She  is  still  fairly  free.  She  said  that  when  she  was 
on  the  ship  things  looked  changed,  "the  picture  over  there  looked 
like  a  saint,  the  beds  looked  queer."  (How  do  things  look  now?) 
"All  right."  (The  picture  too?)  "The  same  as  when  I  was 
going  down  into  a  dark  hole."  When  asked  later  in  the  day 
where  she  was,  she  said,  "In  the  Pope's  house.  Uncle  Edward  is 
it?"  but  after  a  short  time  she  added,  "It  is  Ward's  Island, 
isn't  it?" 

Nov.  11.  Inactive,  inaccessible,  but  for  the  most  part  not 
rigid. 

Nov.  14.  Varies  between  mutism  with  resistance  and  more 
relaxed  inactivity.  To-day  lies  in  a  position  repeatedly  assumed 
by  her,  namely,  on  her  stomach  with  head  raised,  resistive  to- 
wards any  interference,  immobile  face,  totally  inaccessible. 

Nov.  15.  Freer.  She  said :  "One  day  I  was  in  a  coffin,  that's 
the  day  I  went  to  Heaven."  She  also  said  she  used  to  see  "the 
crucifix  hanging  there"  (on  the  ceiling) — "not  now  but  when  I 
was  going  to  Heaven."  (When  was  that?)  "Over  in  that  bed" 
(her  former  bed).  Later  she  added,  "The  place  changed  so  .  .  . 
things  used  to  be  coming  up  and  down  (dreamily) — that  was  the 
day  I  was  coming  up  on  the  ship  or  going  down."  She  is  quite 
oriented. 

Nov.  17.  Usually  stands  about  with  immobile  face,  preoccu- 
pied, but  she  eats  voluntarily. 

Nov.  24.  When  the  husband  and  sister  came  a  few  days  ago 
she  said  she  was  glad  to  see  them,  embraced  them,  cried  and  is 
said  to  have  spoken  quite  freely.  To-day  she  speaks  more  freely 
than  usually.  When  asked  why  she  had  answered  so  little,  she 
said  she  could  not  bring  herself  to  say  anything,  though  she 
added  spontaneously,  "I  knew  what  was  said  to  me."  When 
shown  a  picture  of  her  cataleptic  attitude  with  hands  raised,  she 


IDEATIONAL   CONTENT  OF  THE  STUPOR      89 

said  dreamily,  "I  guess  that  must  have  been  the  day  I  went  to 
Heaven,  everything  seemed  strange,  things  seemed  to  be  going  up 
and  down."  (Did  you  know  where  you  were?)  "I  guess  that 
was  the  day  I  thought  I  was  on  the  ship."  When  the  sister 
spoke  to  her,  she  seemed  depressed  and  said,  "If  only  I  had  not 
done  those  things  I  might  be  saved,  if  I  had  only  gone  to  church 
more." 

Dec.  3.  Seems  depressed.  She  weeps  some,  says  she  is  sad, 
"There  seems  to  be  something  over  my  heart,  so  I  can't  see  my 
little  girls."  Again:  "I  should  have  told  you  about  it  first — I 
should  not  have  bought  it" — (refers  to  buying  carbolic  acid). 
She  wrote  a  natural  letter  but  very  slowly. 

4.  There  followed  then  a  state  lasting  for  six  months,  during 
which  the  patient  was  rather  inactive,  preoccupied,  even  a  little 
tense  at  times.  Sometimes  she  did  not  answer,  again  at  the  same 
interview  spoke  quite  promptly.  For  the  most  part  the  affect 
was  reduced,  at  other  times  she  appeared  a  little  uneasy,  bewil- 
dered, or  again  depressed.  She  said  that  sometimes  a  mist 
seemed  to  be  over  her.  Now  and  then  spoke  of  things  looking 
queer  and  she  asked,  when  the  room  was  cleaned,  "Why  do  they 
move  things  about?"  and  she  added  irrelevantly:  "I  thought  the 
robbers  broke  into  my  house  and  stole  my  wedding  dress  and  my 
children's  dresses  (refers  to  the  condition  during  the  onset  of 
her  psychosis).  In  the  beginning  of  this  state,  when  asked 
about  the  stupor,  she  spoke  again  of  the  "ship"  and  about  going 
"down,  down,"  but  also  said  that  on  one  occasion  she  heard  beau- 
tiful music,  was  waiting  for  the  last  trumpet  and  was  afraid  to 
move.  Moreover,  she  had  some  ideas  referring  to  the  actual 
situation  which  were  akin  to  those  in  the  more  marked  stupor 
period.  Although  she  admitted  she  was  better,  she  said  on  De- 
cember 8  that  she  still  had  queer  ideas  at  times,  "I  sometimes  think 
the  doctor  is  Uncle  Jim"  (long  dead).  She  also  spoke  of  other 
patients  looking  like  dead  relatives,  and  added,  "Are  all  the 
spirits  that  are  dead  over  here?"  "We  never  die  here,  the  spirits 
are  here."  But  after  that  date  no  such  ideas  recurred,  in  fact 
this  whole  period  seems  to  have  been  remarkably  barren  of  delu- 
sions. Exceptionally  isolated  ones  were  noted.  Thus,  on  January 
28  it  is  mentioned  that  she  stated  she  sometimes  felt  so  lonely, 
and  as  though  people  were  against  her;  and  on  February  13  she 


90  BENIGN  STUPOES 

said  she  felt  as  though  the  chair  knew  what  she  was  talking"  about. 
It  is  also  mentioned  in  January  that  she  wept  at  times,  but  this 
seems  not  to  have  been  a  leading  feature  at  all.  In  March,  when- 
asked  why  she  was  not  more  active  and  cheerful,  her  lips  began 
to  quiver  and  she  said,  "Oh,  I  thought  my  children  would  be  cut 
up  in  Bellevue."  "I  don't  know  why  I  feel  that  way  about  them." 
She  sometimes  cried  when  her  friends  left  her. 

5.  Then  followed  a  week  of  a  rather  faultfinding,  self-assertive 
state,  during  which  she  demanded  to  be  allowed  to  go  home,  saying 
indignantly  that  she  was  not  a  wicked  woman,  had  done  nothing 
to  be  kept  a  prisoner  here;  she  wanted  justice  because  another 
patient  had  called  her  crazy.  But  in  this  period  also  she  said 
that  after  the  robbery  (at  home)  she  felt  afraid  that  her  honor 
would  be  taken  away.  When  told  that  her  husband  had  been 
with  her,  she  said  "Yes,  but  I  was  afraid  they  would  get  into  a 
fight."  (You  mean  you  were  afraid  the  other  man  would  kill 
him?)  "No,  he  is  not  dead."  She  further  talked  of  a  disagree- 
ment she  had  at  that  time  with  her  husband,  and  that  she  felt 
then  like  running  away  and  leading  a  bad  life,  but  thought  of 
the  children.  With  tears  she  added :  "I  would  not  do  anything 
that  is  wrong.  I  have  my  children  to  live  for."  Quite  remark- 
able was  the  fact  that  she  then  told  of  various  erotic  experiences 
in  her  life,  though  with  a  distinctly  moral  attitude  and  minimizing 
them. 

6.  On  June  16  another  state  was  initiated  with  peculiar  ideas, 
the  setting  of  which  is  not  known,  as  she  told  them  only  to  the 
nurses.  She  said  that  she  was  not  Mrs.  W.  but  the  Queen  of 
England,  again  that  she  was  an  actress,  or  again  the  wife  of  a 
wealthy  Mr.  B.,  and  that  she  was  going  to  have  a  baby.  But  at 
night  she  is  said  to  have  been  agitated  and  afraid  she  was  to  be 
executed.  She  asked  to  be  allowed  to  go  to  bed  again,  then 
stopped  talking,  and  remained  in  this  mute  condition  for  about 
a  week.  She  often  left  her  bed  and  went  back  again,  remained 
much  with  a  perplexed  expression.  On  one  occasion  she  put 
tinsel  in  her  hair  sajdng  it  was  a  golden  crown. 

7.  At  the  end  of  that  time  she  became  freer  and  more  natural, 
and  remained  so  for  three  weeks.  She  occupied  herself  some- 
what. When  asked  what  had  happened  in  the  condition  pre- 
ceding, said  she  thought  she  was  a  queen  or  was  to  be  a  queen. 


IDEATIONAL   CONTENT   OF  THE   STUPOR      91 

8.  Towards  the  end  of  this  period  she  had  again  three  more 
absorbed  days,  but  when  examined  on  the  third  of  these  days  got 
rather  talkative  and  somewhat  drifting  in  her  talk  on  superficial 
topics. 

9.  Two  days  later  she  began  to  sing  at  night,  kissed  every- 
body, said  it  was  the  anniversary  of  her  meeting  her  husband, 
again  cried  a  little,  and  on  the  following  morning  began  to  sing 
love  songs,  with  a  rather  ecstatic  mood,  and  at  times  stood  in  an 
attitude  of  adoration  with  her  hands  raised.  This  passed  over 
to  a  more  elated  state,  during  which  she  smiled  a  good  deal,  often 
quite  coquettishly ;  she  sang  love  songs  softly;  on  one  occasion 
put  a  mosquito  netting  over  her  head  like  a  bridal  veil;  or  she 
held  her  fingers  in  the  shape  of  a  ring  over  a  flower  pinned  to 
her  breast.  But  even  during  this  state  she  said  little,  only  once 
spoke  of  waiting  for  her  wedding  ring,  and  again,  when  asked 
why  she  had  been  singing,  said  "I  was  singing  to  the  man  I  love." 
(Why  are  you  so  happy?)  "Because  I  am  with  you"  (coquet- 
tishly). 

This,  however,  represented  the  end  of  the  psychosis.  She  im- 
proved rapidly.  At  first  she  smiled  rather  readily,  but  soon  began 
to  occupy  herself  and  made  a  perfect  recovery. 

She  gave  a  rather  shallow  retrospective  account  about  the  last 
phase:  at  first  she  said  it  was  natural  for  people  to  feel  happy 
at  times,  and  that  she  did  not  talk  more  because  the  inclination 
was  not  there.  The  only  point  she  added  later  was  that  she 
held  her  fingers  in  the  shape  of  a  ring  because  she  was  thinking 
of  her  wedding  ring. 

She  was  discharged  on  October  11. 

The  patient  was  seen  again  in  September,  1915.  She  then  stated 
that  she  had  been  perfectly  well  until  1912,  when  she  had  a 
breakdown  after  childbirth.  (A  childbirth  in  1910  had  led  to 
no  disorder.)  The  attack  lasted  six  months.  She  slept  poorly, 
lost  weight,  and  felt  weak,  depressed,  "my  strength  seemed  all 
gone."  In  July,  1915,  following  again  a  childbirth,  she  was  for 
about  six  weeks  "despondent,  weak  and  tired  out." 

At  the  interview  she  made  a  very  natural,  frank  impression, 
and  displayed  excellent  insight. 

Case  13. — Johanna  S.  Age:  47.  Admitted  to  the  Psychi- 
atric Institute  January  23,  1904. 


92  BENIGN  STUPOKS 

F.  H.  It  was  claimed  that  there  was  no  insanity  in  the 
family. 

P.  H.  The  patient  was  said  to  have  been  bright  and  rather 
quick-tempered.  She  came  to  the  United  States  from  Ireland  at 
the  age  of  20,  worked  as  a  servant,  was  well  liked,  and  retained 
her  position  well. 

She  was  married  at  24.  After  a  second  confinement,  at  the  age 
of  26,  the  patient  had  her  first  attack  of  manic  excitement,  from 
which  she  recovered  in  four  months.  She  had,  subsequently,  at 
the  ages  of  28,  30,  32,  35,  43,  and  45,  other  attacks  of  the  same 
nature,  each  one  lasting  about  four  months.  No  precipitating 
cause  was  known  for  any  of  them.  Only  one  of  the  attacks,  the 
fifth,  (none  were  well  observed)  seems  to  have  shown  features 
different  from  an  elated  excitement  with  irritability.  At  the  end 
of  this  attack  she  was  said  to  have  been  "dull"  for  a  month. 

Her  husband  died  four  years  before  the  present  admission,  evi- 
dently soon  after  her  sixth  attack. 

The  present  attack: 

About  two  months  before  admission  the  patient  began,  without 
appreciable  cause,  to  be  sleepless,  complained  of  headaches  and 
appeared  downhearted  and  sad.     She  sat  about. 

After  a  week  she  would  not  get  out  of  bed  and  remained  in 
bed  until  she  was  sent  to  the  Observation  Pavilion,  getting  up 
only  to  go  to  the  closet.  She  said  very  little  and  would  not  eat 
much.  About  a  month  before  admission  she  began  to  say  that 
she  did  not  want  to  live,  begged  her  daughter  to  throw  her  out 
of  the  window.  About  two  weeks  before  admission  she  began 
to  insist  that  she  heard  the  voice  of  her  brother  (living  in  Ireland) 
calling  her.     She  got  out  of  bed  to  look  for  him. 

At  the  Observation  Pavilion  she  was  described  as  slow,  looking 
about  in  an  apprehensive  manner,  bewildered,  dazed,  saying  "I 
am  dead — there  is  poison  in  it  (not  clear  in  what) — I  am  dead, 
you  are  dead." 

Under  Observation:  1.  On  admission  the  patient  had  a  coat- 
ed tongue,  foul  breath,  constipation,  lively  knee-jerks  and  a  pulse 
of  110.  She  appeared  dull,  inactive,  lay  in  bed  with  her  eyes 
closed.  She  would  open  them  when  urged  but  appeared  drowsy 
and  her  face  was  strikingly  immobile.  At  times  she  moaned  a 
little.     She  could  be  made  to  respond  in  various  ways  such  as 


IDEATIONAL   CONTENT   OF  THE   STUPOR      93 

shaking  her  head,  or  making  some  motions  as  though  to  indicate 
that  she  could  not  give  any  explanations.  All  movements  were 
slow.     She  also  responded  to  a  few  questions  by  "I  don't  know." 

Two  days  after  admission  the  condition  was  not  essentially 
different  except  that  she  was  a  little  uneasy  when  urged  to  speak, 
corrugated  her  forehead,  said  "Everything  is  dark,"  again  "I  am 
very  sick,"  or  she  turned  away  her  head. 

On  the  fourth  day,  i.  e.,  January  26,  the  picture  altered,  inas- 
much as  she  was  much  more  responsive.  She  was  found  sitting  up 
in  bed  and,  at  times,  a  little  uneasy.  She  was  slow  in  her  move- 
ments and  answers,  speaking  in  a  whisper  and  sometimes  a  little 
fretfully.  The  answers,  though  slow,  were,  however,  by  no  means 
given  in  the  shortest  possible  manner,  but  with  variations,  e.  g., 
from  "I  don't  know,"  to  "I  could  not  tell  you,"  or  "I  can't  tell 
that  either."  She  said  herself  that  everything  had  "been  so  dark 
— it  is  light  now,  but  it  gets  so  dark  sometimes."  She  denied 
knowing  where  she  was,  even  in  what  city,  also  denied  knowing 
the  month,  adding  to  the  latter  answer  "the  nurse  can  tell  you." 
She  could  not  tell  where  she  had  been  before  coming  to  the  hos- 
pital, or  how  she  came.  Finally,  she  also  claimed  not  to  know 
her  age,  her  birthday  or  the  date  of  her  marriage;  but  she  gave 
the  current  year  correctly,  the  place  where  she  went  to  school, 
the  names  of  some  of  her  teachers,  and  the  year  of  her  arrival 
in  the  United  States.  She  also  stated  in  aswer  to  questions  that 
she  came  to  the  hospital  "to  get  well."  She  repeatedly  said  "I 
am  so  sick,"  or  "I  am  so  stupid,"  or  "My  mind  is  mixed  up, 
twisted,"  or  "My  mind  is  not  so  good,"  or  "I  am  so  tired." 
What  could  be  obtained  of  a  content  was  as  follows :  When  she 
spoke  of  being  "twisted,"  she  said,  "I  got  all  kinds  of  medicine." 
(How  does  it  affect  you?)  "Through  my  head  and  it  made  me  hot 
inside."  Again,  when  asked  whether  anybody  had  done  anything 
to  her,  she  said  "No,  I  have  done  wrong  myself,  by  speaking 
bad  of  my  neighbors."  She  claimed  to  hear  voices  "all  over," 
but  could  not  tell  what  they  said.  When,  in  the  evening  of  that 
day,  the  nurse  asked  her  why  she  did  not  talk  more,  she  said, 
"God  damn  it,  I  am  all  twisted,  my  brain  is  mixed  up,  my  sys- 
tem is  all  upset,  the  doctor  made  me  stupid  with  questions,  and 
the  medicine  I  have  taken  made  me  all  stupid  and  I  am  inhaling 
gas  now."   Then  she  again  settled  into  a  dull  state  and  was  found 


94  BENIGN  STUPORS 

by  the  physician  with  immobile  expression,  slow  motions  and 
mute. 

2.  For  about  ten  days,  i.  e.,  from  January  27  to  February  8, 
her  condition  was  of  a  more  pronounced  character.  For  the 
most  part  she  lay  in  bed  with  often  quite  immobile  face  and  with 
eyes  closed,  or  she  looked  about  in  a  bewildered  manner.  She 
was  very  inactive,  presented  a  marked  resistance  in  her  arms  and 
jaw  when  passive  motions  were  attempted,  or,  again,  exhibited 
decided  catalepsy.  She  had  to  be  tube-fed.  Once  on  the  27th  of 
January,  when  the  nurse  tried  to  feed  her,  she  pushed  her  away 
and  said,  "I  am  dead — I  am  not  home."  Sometimes  she  turned 
her  hands  about  with  slow  tremulous  movements,  looking  at  them 
in  a  bewildered  manner. 

She  usually  was  mute,  except  on  the  few  occasions  to  be  men- 
tioned later,  as  well  as  on  February  3,  when  she  was  generally 
a  little  more  responsive.  At  that  time  she  could  be  made  to  open 
her  eyes,  and  then  replied  to  a  few  questions  slowly  and  in  a 
low  tone;  others  were  left  unanswered.  (To  the  questions  where 
she  was  and  how  long  she  had  been  here,  she  replied  with  "I 
don't  knoM^,"  but  to  questions  about  who  the  physician  and  the 
nurse  were,  by  saying  "You  are  a  doctor,"  and  "she  is  a  nurse.") 

In  the  general  setting  just  described  there  occurred  at  various 
times  changes  in  behavior  which  were  as  follows :  On  the  evening 
of  the  27th  of  January  she  got  out  of  bed  and  walked  about 
with  slow  restlessness,  saying:  "They  say  I  am  going  to  be  cut 
up."  On  February  1,  she  was  seen  for  a  time  making  peculiar 
slow  swimming  motions  with  her  hands.  Again  on  the  3d  of 
February  she  got  out  of  bed,  walked  about  slowly,  with  peculiar 
steps,  as  though  avoiding  stepping  on  something.  Next  day  (the 
4th)  she  sat  up  in  bed — again  made  at  times  her  peculiar  slow 
swimming  motions.  She  presented  at  the  same  time  a  peculiar 
dazed  bewildered  uneasiness  and,  when  questioned  what  was  the 
matter,  said :  "I  am — I  am — at  the  bottom  of  the  deep — deep 
water — oh — oh — the  deep — deep — dark  water."  And  when  fur- 
ther urged  she  added  with  the  same  manner,  "I  can't  swim — I 
don't  know — but  the  place" — She  did  not  finish  but  later  again 
muttered  "the  deep — deep — dark  water."  (Do  you  really  think 
you  are  in  the  water?)     "I  don't  know — ^my  head  is  so  bad." 

For  the  following  five  days  this  behavior  was  repeated  from 


IDEATIONAL   CONTENT  OF  THE   STUPOR      95 

time  to  time,  when  she  would  sit  up  and  with  bewildered  uneasi- 
ness make  slow  swimming  motions  and  mutter  when  questioned, 
^'I  am  in  the  deep,  dark  water." 

Some  other  emotional  responses  in  reaction  to  external  events 
must  still  be  mentioned.  They  were  rare.  On  February  1  the 
patient's  daughter  came  while  she  was  lying  motionless  in  bed. 
She  slowly  extended  her  hands,  tried  to  speak,  and  then  her  eyes 
filled  with  tears.  Again,  at  the  end  of  the  interview  of  Febru- 
ary 3,  after  she  had  made  a  few  replies,  she  settled  down  to  her 
usual  inactivity  and,  when  further  urged  to  answer,  her  eyes 
filled  with  tears. 

3.  From  about  February  9  to  February  24  the  condition  again 
presented  a  different  aspect,  inasmuch  as  while  there  was  still 
a  marked  reduction  of  activity,  she  showed  this  to  a  decidedly 
lesser  degree.  Moreover,  there  was  no  bewilderment  at  any  time. 
No  resistance,  but  cataleptic  tendencies  were  still  seen  occasion- 
ally. There  was  at  no  time  the  peculiar  dazed  uneasiness  and 
slow  restlessness  associated  with  the  idea  of  being  in  the  deep, 
dark  water. 

She  now  dressed  herself  very  slowly,  ate  slowly  but  of  her  own 
accord,  and  spoke,  though  her  voice  was  consistently  slow,  in  a 
low  tone  and  her  words  were  few. 

At  the  beginning  of  this  period  on  February  9,  when  asked 
how  she  was,  she  said  "I — I  am  sick."  To  the  questions  as  to 
where  she  was,  how  long  she  had  been  here  and  how  she  had  been 
taken  sick,  she  replied  by  saying  "I  don't  know."  But  she  knew 
she  was  in  a  hospital,  had  been  here  before  "many  times.'^  (Cor- 
rect.) She  was  then  again  asked  for  the  name  of  the  hospital, 
but  replied  "I  don't  know."  So  the  physician  pointed  out  of 
the  window  and  asked  her  what  it  was  that  she  could  see  there 
(the  East  River).  She  replied,  "It  is  the  dark  water.  Some- 
times I  go  there  and  don't  come  back  again — and — something 
throws  me  up  and  I  come  back."  (What  has  been  the  matter 
with  you?)  "I  have  been  sick  all  this  time."  Again,  "I  can't 
tell — I  am  not  a  good  woman — I  am  very  sick."  (Why  do  you 
say  you  are  not  a  good  woman?)  "Oh,  I  did  not  do  things 
right." 

At  a  later  interview,  during  the  same  period,  she  knew  the 
doctor's  name,  knew  she  had  seen  him  at  Ward's  Island,  knew 


96  BENIGN  STUPORS 

she  was  in  a  hospital,  but  somehow  could  not  connect  the  present 
place  with  Ward's  Island.  She  said  she  didn't  know,  when  asked 
where  she  was,  and  when  questioned  about  the  season,  said,  after 
a  pause  "Summer"   (February  15). 

We  have  seen  above  that  she  once  spoke  of  not  having  been  a 
good  woman.  She  repeated  this  on  February  10,  said  "I  have 
done  lots  of  harm,  I  have  been  a  bad  woman  all  my  life."  Again : 
"I  had  bad  thoughts."  (What  kind?)  "I  have  forgotten  all 
about  them."  It  should  be  added  that  at  this  interview  she  also 
said,  "My  mind  is  better  now." 

On  February  25  there  was  a  sudden  change.  She  laughed 
when  a  funny  remark  was  made  on  the  ward.  Later,  when  the 
physician  came  to  her,  she  still  lay  in  bed  inactive  and  had  to  be 
urged  considerably  at  first,  but  presently  began  to  laugh  good- 
naturedly  and  quite  freely  commented  on  the  funny  remark  she 
had  heard  earlier  in  the  morning,  and  on  peculiarities  of  some 
patients.  She  spoke  quite  freely  and  without  constraint.  But  it 
was  striking  how  little  account  of  the  condition  she  had  gone 
through  could  be  obtained  from  her.  She  either  turned  the 
questions  off  by  flippant  remarks,  or  said  she  did  not  know.  The 
only  information  obtained  was  that  she  had  been  sick  since 
Christmas,  felt  like  a  dummy,  that  she  had  lost  track  of  time, 
and  did  not  know  how  she  had  felt  during  that  period.  When 
asked  why  she  had  not  spoken,  she  said,  "I  couldn't,  I  had  a 
jumping  toothache,"  or  she  said,  "Ask  the  nurse,  she  put  it  down 
in  the  book."  Or  again  she  said,  "Did  you  ever  get  drunk? 
That  is  the  way  I  felt.     I  felt  like  dead." 

She  soon  developed  a  lobar  pneumonia  and  died. 

The  following  typical  case  of  partial  stupor  is 
quoted  as  an  example  of  delusions  appearing  only 
during  the  onset. 

Case  14. — Maggie  H.  Age:  26.  Admitted  to  the  Psychi- 
atric Institute  February  8,  1905. 

F.  H.  The  father  died  when  33.  The  mother  was  living. 
Psychopathic  tendencies  were  denied. 

P.  H.     The  husband  and  brother  stated  that  the  patient  was 


IDEATIONAL   CONTENT  OF  THE   STUPOR      97 

natural,  capable,  rather  jolly.  She  married  about  a  year  before 
admission  and  shortly  became  pregnant.  During  the  pregnancy 
she  was  rather  nervous  and  had  various  forebodings,  among 
which  were  that  the  child  might  be  born  deformed,  or  that  she 
would  die  in  childbirth. 

The  baby  was  born  three  weeks  before  admission.  The  patient 
seemed  much  worried  immediately  after  the  childbirth,  fretted 
about  not  having  enough  milk,  was  quite  concerned  about  her 
husband  and  did  not  want  him  to  leave  her  side.  The  brother 
stated  that  about  this  time  the  patient  heard  that  the  husband 
was  out  of  work.  She  worried  about  this  and  told  her  sister  so. 
She  also  began  to  say  that  her  head  was  getting  queer.  On  the 
fifth  day  after  childbirth,  a  change  came  over  the  patient.  She 
cried  and  said  she  was  going  to  die.  She  also  spoke  of  poison 
in  the  food  and  accused  the  husband  of  unfaithfulness.  The 
next  day  she  became  silent,  "did  not  seem  to  want  to  have  any- 
thing to  do  with  anybody,"  lay  in  bed,  had  a  tendency  to  pull 
the  covers  over  her  head  and  scarcely  ever  spoke.  But  during 
this  period  she  continued  to  look  after  the  baby  faithfully. 
Sometimes  she  clung  to  her  husband,  saying  she  was  afraid  he 
was  going  to  die. 

After  recovery  the  patient  said  that  while  she  was  at  home  she 
thought  she  saw  bodies  lying  about. 

At  the  Observation  Pavilion  she  was  quiet  and  apathetic,  in- 
different to  environment  and  could  not  be  induced  to  speak. 
She  soiled,  refused  food,  and  was  resistive  when  anything  was 
done  to  her. 

Under  Observation.  1.  On  admission  the  patient  was  fairly 
well  nourished  but  looked  rather  anemic  and  weak.  The  tempera- 
ture was  normal,  the  pulse  a  little  irregular  but  of  normal  fre- 
quency, the  tongue  coated.  She  lay  inactive  but  looked  about, 
and  the  facial  expression  sometimes  changed  as  she  did  this.  Any 
interference  met  with  intense  resistance.  There  was  no  catalepsy. 
In  contradistinction  to  this  inactivity  and  resistance,  natural, 
free  motions  were  observed  at  times,  as,  for  example,  when  she 
arranged  her  pillows.  She  did  not  speak  and  could  not  be  made 
to  answer. 

For  the  rest  of  the  first  week  she  made  no  attempt  to  speak, 
except  once  when  she  seemed  to  attempt  to  return  a  "good  morn- 


98  BENIGN  STUPORS 

ing,"  or  on  another  occasion,  when  the  nurse  tried  to  feed  her,  she 
said,  in  quite  a  natural  tone,  "I  can  feed  myself."  The  re- 
sistance to  interference  remained  in  a  variable  degree,  and  was 
at  times  quite  strong.  It  was  largely  passive,  though  not  infre- 
quently associated  with  a  scowl,  or  she  moved  away  when  ap- 
proached. She  sometimes  looked  dull  and  stared,  again  she 
looked  determined,  "disdainful,"  or  scowled;  or  she  looked  about 
watching  others,  sometimes  only  out  of  the  corners  of  her  eyes. 
She  had  to  be  spoon-fed  at  times,  again  she  ate  naturally  when 
the  food  was  brought.  Repeatedly,  when  taken  out  of  bed, 
though  she  resisted  at  first,  she  dressed  with  natural  free  mo- 
tions.    She  always  retracted  promptly  from  pin  pricks. 

Towards  the  end  of  the  week  she  even  complied  at  times  with 
a  request  to  do  some  work,  but  on  the  same  day  she  would  remain 
passive,  with  a  look  of  disdain,  or  resist  intensely  when  inter- 
fered with,  e.  g.,  when  an  attempt  was  made  to  make  her  sit 
down.     She  never  soiled  and  never  showed  any  catalepsy. 

2.  Then  the  condition  changed,  inasmuch  as  the  marked  resist- 
ance ceased  entirely,  and  the  mutism  gave  way  first  to  slow  and 
low  answers,  and  later  to  much  freer  speech,  though  the  inac- 
tivity improved  only  gTadually.  Thus  at  the  examination  on 
Februarj^  19,  though  she  was  quite  inactive,  she  answered  some 
questions,  albeit  in  whispers  and  briefiy.  This  was  the  case 
when  questioned  about  the  year,  month  and  date,  which  she  gave 
correctly,  but  she  merely  shook  her  head  when  asked  how  long 
she  had  been  here,  why  she  was  here,  what  was  the  matter  with 
her.  Once  she  smiled  appropriately.  Later  she  became  freer  in 
speech,  with  a  more  natural  tone,  although  her  answers  continued 
to  be  short.  Not  infrequently^,  when  asked  to  calculate  or  to 
write,  she  would  not  cooperate,  saying  "This  has  nothing  to  do 
with  my  getting  well,"  or  (later)  "What  has  that  got  to  do  with 
my  going  home?"  or  she  would  simply  say  she  did  not  want  to. 
Improvement  in  her  listlessness  and  inactivity  was  more  gradual. 

The  prevailing  affective  state  was  indefinite.  She  denied  re- 
peatedly that  she  was  depressed,  though  later  she  admitted  once 
being  downhearted,  yet  it  seems  that  even  then  her  mood  was  not 
so  much  one  of  sadness  as  of  a  slight  resentment.  On  one  occa- 
sion, however,  she  showed  some  tears  when  asked  about  the  baby. 
She  repeatedly  expressed  the  wish  to  go  home,  but  not  in  a  plead- 


IDEATIONAL   CONTENT   OF  THE   STUPOR      99 

ing,  rather  in  a  resentful,  way,  saying  she  would  never  be  better 
here,  that  the  questions  which  were  asked  had  nothing  to  do  with 
her  going  home,  that  she  would  be  all  right  if  she  went  home. 
She  never  admitted  that  she  had  ever  been  sick  enough  to  be 
taken  to  a  hospital,  though  she  quite  appreciated  that  there  had 
been  something  the  matter  with  her  head  at  home  and  in  the  hos* 
pital.  She  stated,  in  answer  to  questions,  that  she  had  a  peculiar 
feeling  in  the  head  which  she  could  not  explain,  that  she  could 
not  remember  so  well  as  formerly.  Once  she  said,  "I  hear  so 
much  around  here  that  my  head  gets  so  full." 

When  towards  the  end  she  was  questioned  about  her  condition, 
i.  e.,  the  reason  for  her  resistance,  her  mutism,  and  her  refusal 
of  food,  she  said  that  then  she  "wanted  to  be  left  alone";  that 
she  did  not  eat  "because  she  did  not  want  food,"  and  she  also 
spoke  of  not  having  had  any  interest. 

She  was  discharged  on  April  29,  i.  e.,  about  ten  weeks  after 
admission  before  she  had  become  entirely  free. 

The  last  case  is  interesting  in  that  a  depressive 
onset  to  a  deep  stupor  was  observed  in  the  Institute. 
It  was  characterized  by  constant  repetitions  of  a  re- 
quest to  be  killed. 

Case  15. — Meta  S.  Age:  16.  Admitted  to  the  Psychiatric 
Institute  June  26,  1902. 

F.  H.  The  father  was  dead,  and  the  mother  living  abroad. 
Not  much  could  be  learned  about  them  and  the  immediate  family. 

P.  H.  An  aunt  who  gave  the  anamnesis  had  known  the  patient 
only  since  she  came  to  the  United  States,  a  year  before  admis- 
sion. After  her  arrival  the  patient  at  once  went  to  work  as  a 
servant.  It  was  claimed  that  her  employer  liked  her,  but  that  she 
was  rather  slow  about  the  work.  The  only  trouble  known  was 
that  she  sometimes  complained  of  indigestion.  She  went  to  see 
her  aunt  about  once  every  two  weeks. 

Three  weeks  before  admission,  when  the  patient  visited  her 
aunt,  she  seemed  quieter  than  usual.  Further,  she  spoke  about 
sending  money  home  on  the  Kaiser  Wilhelm  der  Grosse,  which 
was  thought  peculiar  because  she  had  no  money,  and  on  a  walk 


100  BENIGN  STUPORS 

through  a  cemetery  said  "I  would  like  to  be  here  too."  At  the 
time  this  did  not  impress  the  aunt  as  very  peculiar.  The  patient 
continued  to  work  until  nine  days  before  admission.  The  em- 
ployer then  sent  for  the  aunt  and  said  the  patient  had  been  very 
quiet  for  about  two  weeks,  and  that  she  now  had  become  more 
abnormal.  She  suddenly  had  begun  to  cry,  said  the  police  had 
come,  claimed,  without  foundation,  that  she  had  "stolen,"  and 
kept  repeating  "I  have  done  it,  I  will  not  do  it  again."  The 
aunt  took  her  home  with  her.  There  she  was  quite  dejected, 
cried,  spoke  of  killing  herself  (wanted  to  jump  out  of  the  window, 
wanted  to  get  a  knife).  On  the  whole,  she  said  very  little,  but 
when  the  aunt  pressed  her  to  say  why  she  was  so  worried,  she 
said  she  had  allowed  men  to  kiss  her  and  had  taken  money  from 
them.     It  is  claimed  that  she  never  menstruated. 

After  recovery  the  patient  herself  described  the  onset  as  fol- 
lows :  Ever  since  she  came  to  this  country  she  had  been  homesick, 
and  felt  especially  lonesome  for  some  months  before  admission. 
She  knew,  however,  of  no  precipitating  cause,  in  spite  of  what 
she  had  said  to  the  aunt  and  what  she  said  at  first  under  observa- 
tion. She  consistently  denied  that  anything  had  happened  with 
young  men.  A  short  time  before  she  left  her  place  (she  left 
it  nine  days  before  admission)  she  could  not  work,  began  to  ac- 
cuse herself  of  being  a  bad  girl  and  of  having  stolen.  Then 
she  was  taken  to  the  aunt's  house.     There  she  wanted  to  die. 

Under  Observation.  1.  On  admission  the  patient  appeared  de- 
pressed, sat  with  downcast  expression,  looking  up  rarely.  She 
spoke  in  a  low  tone  and  slowly.  But,  in  spite  of  delay,  she  an- 
swered all  questions,  knew  where  she  was  and  gave  an  account  of 
the  place  where  she  had  worked.  When  questioned  about  trouble 
with  men,  she  claimed  that  a  man  who  lived  in  the  same  house 
where  she  worked  had  tried  to  make  her  "lie  on  the  bed,"  but  that 
she  refused;  that  later  a  man  had  assaulted  her  and  had  after 
that  repeatedly  come  to  her  room  when  she  was  alone.  Yet  when 
asked  whether  she  worried  about  this,  she  denied  it. 

2.  For  eight  days  her  condition  was  sometimes  one  of  marked 
reduction  of  activity,  with  preoccupation.  She  sat  in  a  dejected 
attitude,  and  had  to  be  urged  to  do  anything.  Sometimes  she 
was  very  slow  in  greeting  and  slow  in  answering,  and  said  very 
little.     But  whenever  spoken  to  she  was  apt  to  cry  and  this  might 


IDEATIONAL   CONTENT  OF  THE  STUPOR    101 

lead  to  such  distress  that  the  reduction  of  activity  was  no  longer 
to  be  seen.  Thus  on  June  28,  when  greeted,  she  began  to  cry 
and  say,  "Oh,  what  have  I  done! — Oh,  just  cut  my  head  of£ — Oh, 
please  what  have  I  done — I  have  given  my  hand."  (Tell  me  the 
whole  story.)  Imploringly  and  with  hands  clasped:  "No,  I  can't 
do  it — ^just  cut  my  head  off,  please,  please."  (Why  can  you 
not  tell  me?)  "Oh,  what  have  I  done!"  The  imploring  to  cut 
her  head  off  was  then  several  times  repeated,  and  she  could  not 
be  made  to  answer  orientation  questions.  On  June  29  she  be- 
came agitated  spontaneously  and  cried  loudly,  saying,  "Oh,  let  me 
go  home  and  die  with  my  father."  She  was  then  put  to  bed,  and 
when  seen  she  could  not  be  made  to  answer  orientation  questions. 
But  when  asked  whether  she  had  seen  the  physician  before,  she 
said,  "I  saw  you  yesterday."  She  could  not  be  made,  however, 
to  say  how  long  she  had  been  here,  "I  think  a" — not  finishing 
the  sentence.  Although  she  would  not  answer  further,  she  pres- 
ently began  to  say  "Oh,  cut  my  head  off — oh,  where  is  my  papa 
and  mamma?"  When  told  that  her  people  were  in  Germany 
and  that  she  could  go  back  to  them,  she  said  "I  haven't  any 
money  to  pay  it."  Then  she  wanted  to  know  if  she  was  to  pay 
for  her  board  and  bed  and  said  she  could  not  do  it. 

Again,  on  July  1,  although  she  had  been  quite  preoccupied, 
inactive  and  silent,  she  began  to  say  when  greeted,  "Oh,  please 
cut  my  head  off."  But  she  then  answered  some  questions,  said 
she  had  not  worked  enough.  On  questioning,  she  explained  it 
was  not  that  the  work  had  been  too  much,  but  that  she  had  been 
nervous,  had  tried  to  work  as  much  as  the  servant  next  door, 
but  could  do  only  half  as  much,  "Oh,  I  ought  to  have  worked." 

Repeatedly  on  other  occasions  she  begged,  with  distress,  to 
have  her  head  cut  off  or  to  be  killed.  Frequently  there  were 
statements  of  self -blame :  she  ought  to  have  worked  more,  was 
lazy  or  "I  am  not  worthy";  or  she  said  she  had  lied  and  stolen; 
or  again,  "I  have  not  paid  for  these  beds  and  I  cannot,"  or  "I 
am  a  bad  girl." 

3.  For  a  month  she  presented  a  more  marked  reduction  of  ac- 
tivity. She  sat  about  with  a  dejected  look,  often  gazed  in  a  pre- 
occupied manner,  or  she  stood  or  walked  around  slowly.  Some- 
times she  had  to  be  spoon-fed.  At  other  times  she  ate  slowly. 
Toward   the  latter  part  of  this  period,  a  distinct  tendency   to 


102  BENIGN  STUPORS 

catalepsy  appeared.  During  this  period,  too,  as  a  rule  (though 
not  alwaj^s),  she  would  cry  when  spoken  to.  A  few  times  she 
would  make  some  ineffectual  motions  when  questioned,  but  she 
scarcely  ever  spoke. 

4.  Then  followed  a  period  again  lasting  about  one  month  in 
which  the  picture  was  at  times  one  of  still  greater  inactivity.  She 
would  retain  uncomfortable  positions,  allow  flies  to  crawl  over 
her  face.  She  presented  resistance  in  the  jaws,  did  not  react 
to  pin  pricks.  She  sometimes  sat  with  eyes  closed  or,  with  an 
immobile  face,  the  eyes  stared  with  little  blinking.  The  catalepsy 
was  more  decided.  She  often  would  not  swallow  solid  food  but 
swallowed  fluid.  Again  she  held  her  saliva,  sometimes  drooled. 
Once  she  held  her  urine  and  had  to  be  catheterized.  When 
spoken  to  she  once  smiled  at  a  joke,  sometimes  there  was  no 
response,  but  as  a  rule  there  were  tears  or  flushing  of  the  face. 
On  the  physical  side,  there  were  marked  dermatographia  and, 
for  a  time,  towards  the  end  of  the  period,  profuse  sweating. 
Throughout  the  stupor  proper  her  temperature  was  between  99° 
and  100°  as  a  rule. 

5.  The  period  which  followed  and  which  lasted  about  two 
months  was  characterized,  like  the  one  just  described,  by  marked 
stupor  symptoms,  associated,  however,  with  more  resistance, 
while  the  crying  practically  disappeared.  On  the  other  hand,  a 
number  of  plainly  angry  reactions  were  seen  and,  towards  the 
end,  smiling  and  laughing.  She  lay  in  bed,  on  her  back,  staring, 
allowing  the  flies  to  crawl  over  her  face;  retained  uncomfortable 
positions  without  correcting  them,  and  her  arms  often  showed  a 
decided  tendency  to  catalepsy.  Sometimes  she  soiled.  She  con- 
stantly held  saliva  in  her  mouth,  though  she  did  not  often  drool. 
She  was  totally  mute,  did  not  respond  in  any  way  except  in  the 
manner  to  be  presently  indicated.  She  had  to  be  tube-fed  a 
good  part  of  the  time,  was  quite  resistive  when  an  attempt  was 
made  to  open  her  mouth.  When  attended  to  by  the  nurse,  she 
was  apt  to  make  herself  stiff.  But  as  a  rule,  she  was  not  resistive 
to  passive  motions  when  tested.  On  a  few  occasions  she  had,  as 
was  stated,  marked  angry  outbursts.  Thus  on  one  occasion  when 
her  temperature  was  taken  she  angrily  pushed  the  nurse  away 
and  then  struggled  vigorously.  On  another  occasion,  when  the 
bed-pan  was  put  under  her,  she  threw  it  away  angrily  and  struck 


IDEATIONAL   CONTENT   OF   THE   STUPOR    103 

the  nurse;  once  she  did  the  same  with  the  feeding  tube.  She 
struck  a  patient,  on  another  occasion,  when  the  latter  came  to 
her  bed.  On  two  occasions  she  suddenly  threw  herself  headlong 
on  the  floor.  Towards  the  end  of  the  period,  when  the  blood- 
pressure  was  taken,  she  smiled  and  then  laughed  out  loud.  She 
could  be  made  to  smile  again  later. 

6.  The  last  period,  before  the  more  definite  improvement,  lasted 
about  a  month.  She  was  inactive  and  slow,  ate  slowly  (feeding 
no  longer  necessary),  and  was  mute.  But  she  did  not  stare,  was  no 
longer  resistive,  no  longer  held  saliva.  She  appeared  indifferent, 
but  could  be  made  to  smile  quite  readily  when  spoken  to. 
On  one  occasion  she  laughed  out  loud  when  a  comical  toy  was 
shown  her,  again  was  amused  at  a  party.  In  the  beginning  of 
the  period  she  was  once  seen  to  cry  a  little  when  sitting  by  her- 
self, and  at  the  same  time  wept  a  little  when  spoken  to,  but  this 
was  now  isolated.  Towards  the  end  of  the  period  she  spoke  a 
little,  asked  for  paper  and  pencil  and  wrote:  "Dear  Mother. — 
I  only  take  up  the  pencil  in  order  to  write  you  a  few  lines.  We 
are  all  cheerful  and  in  good  health  and  hope  that  you  are  the 
same  and  we  congratulate  you  on  your  birthday  19th  of  December 
that  I  have  not  written  to  you  for  a  long  time  were  in  the  same 
..."     (Translated.)     This  was  written  very  slowly. 

On  the  day  after  this  letter  she  was  distinctly  freer,  talked  a 
little  to  the  nurse  and  then  improved  rapidly.  A  week  after 
this,  January  16,  she  is  described  as  quite  free  in  her  talk  and 
activity,  but  when  asked  about  the  psychosis  she  merely  shrugged 
her  shoulders.  However,  mere  extensive  retrospective  accounts 
were  taken  later. 

The  retrospective  accounts  were  obtained  on  January  24  and 
March  13.  As  these  two  accounts  do  not  seem  to  be  funda- 
mentally different  for  the  period  of  the  psychosis,  they  may  here 
for  the  sake  of  brevity  be  combined. 

She  remembered  clearly  going  to  the  Observation  Pavilion, 
and  feeling  frightened,  as  she  did  not  know  where  she  was  going 
and  what  they  were  going  to  do  with  her.  She  knew  when  she 
was  in  the  Observation  Pavilion  and  had  a  good  recollection  of 
the  place,  also  of  the  transfer  to  the  hospital,  the  ward  she  came 
to,  who  spoke  to  her,  etc.  She  did  not  know  what  the  place  was 
until  the  doctor  told  her  a  day  or  two  after  admission.     Unfor- 


104  BENIGN  STUPORS 

tunately  definite  incidents  were  inquired  into  only  for  the  first 
part  (July).  But  she  remembered  those  clearly.  She  also 
claimed  to  remember  all  visits  which  were  made  to  her  by  her 
friends,  but  it  was  not  specifically  determined  whether  there  was 
a  period  of  less  clear  recollection  or  not.  However,  she  remem- 
bered the  tube-feeding,  which  occurred  only  during  the  more 
marked  stupor.  Her  desire  to  be  killed,  to  have  her  head  cut 
off,  she  recalled  but  claimed  not  to  know  why  she  wanted  to  be 
killed.  However,  she  remembered  worrying  about  being  bad, 
about  the  fact  that  she  could  not  "pay  for  the  beds,"  etc. 

Her  mutism  and  refusal  of  food  she  was  unable  to  account 
for.  She  could  not  talk,  her  "tongue  would  not  move."  As  re- 
gards ideas  during  the  more  stuporous  period,  she  claimed  that 
(when  quite  inactive)  she  heard  voices  but  did  not  recall  what 
they  said.  But  she  remembered  having  dreams  at  that  time  "of 
fire,"  "of  her  dead  father  and  of  home." 

In  a  survey  of  thirty- six  consecutive  cases  of 
definite  stupor,  literal  death  ideas  were  found  in  all 
but  one  case.  They  seem  to  be  commonest  during  the 
period  immediately  preceding  the  stupor,  as  all  but 
five  of  these  cases  spoke  of  death  while  the  psychosis 
was  incubating.  From  this  we  may  deduce  that  the 
stupor  reaction  is  consequent  on  ideas  of  death,  or, 
to  put  it  more  guardedly,  that  death  ideas  and 
stupor  are  consecutive  phenomena  in  the  same  fun- 
damental process.  Two-thirds  of  these  patients 
interrupted  the  stupor  symptoms  to  speak  of  death 
or  attempt  suicide,  which  would  lead  us  to  suppose 
that  this  intimate  relationship  still  continued.  One- 
quarter  gave  a  retrospective  account  of  delusions  of 
being  dead,  being  in  Heaven,  and  so  on.  From  this 
we  may  suspect  that  in  many  cases  there  may  be  a 
thought  content,  although  the  patient's  mind  may 


IDEATIONAL   CONTENT  OF  THE  STUPOR    105 

seem  to  be  a  complete  blank.  It  is  important  to  note 
that  when  a  retrospective  account  is  gained,  the 
delusions  are  practically  always  of  death  or  some- 
thing akin  to  it,  such  as  being  in  prison,  feeling 
paralyzed,  stiff,  and  so  on. 

In  the  one  case  of  the  thirty-six  who  presented  no 
literal  death  ideas,  the  psychosis  was  characterized 
essentially  by  apathy  and  mild  confusion,  a  larval 
stupor  reaction.  It  began  with  a  fear  of  fire,  smell- 
ing smoke  and  a  conviction  that  her  house  would 
burn  down.  It  is  surely  not  straining  interpretation 
to  suggest  that  this  phobia  was  analogous  to  a  death 
fear.  When  one  considers  the  incompleteness  of 
anamneses  not  taken  ad  hoc  (for  these  are  largely 
old  cases)  and  that  the  rule  in  stupor  is  silence,  the 
consistence  with  which  this  content  appears  is 
striking. 

To  exemplify  the  form  in  which  these  delusional 
thoughts  occur  we  may  cite  the  following:  Henri- 
etta H.  (Case  8)  said,  retrospectively,  that  she 
thought  she  was  dead,  that  she  saw  shadows  of  dead 
friends  laid  out  for  burial,  that  she  saw  scenes  from 
Heaven  and  earth.  Annie  K.  (Case  5)  claimed  to 
have  had  the  belief  that  she  was  going  to  die,  and  to 
have  had  visions  of  her  dead  father  and  dead  aunt, 
who  were  calling  her.  She  also  thought  that  all  the 
family  were  dead  and  that  she  was  in  a  cemetery. 
Rosie  K.  (Case  11)  said  she  had  the  idea  that  she 
wanted  to  die  and  that  she  refused  food  for  that 
purpose,  and  during  the  stupor  she  sometimes  held 
her  breath  until  she  was  cyanotic.    Mary  F.  (Case 


106  BENIGN  STUPOES 

3),  before  her  stupor  became  profound,  spoke  of  the 
hereafter,  of  being  in  Calvary  and  in  Heaven.  In 
this  case,  as  well  as  in  the  above-mentioned  Henrietta 
H.,  we  find,  therefore,  associated  with  ''death"  the 
closely  related  idea  of  Heaven.  Whether  Calvary 
merely  referred  to  the  cemetery  (Mt.  Calvary  Ceme- 
tery) or  leads  over  to  the  motif  of  crucifixion,  cannot 
be  decided.  It  is,  however,  clear  that  this  latter 
motif  may  be  associated  with  that  of  death,  as  is 
shown  in  Charlotte  W.  (Case  12),  who,  during  inter- 
vals when  the  inactivity  lifted,  spoke  of  having  been 
dead,  of  spirits  having  told  her  that  she  must  die,  of 
having  gone  to  Heaven,  of  God  having  told  her  that 
she  must  die  on  the  cross  like  Christ.  But  this  pa- 
tient also  showed  in  a  second  subperiod  of  her 
stupor  another  content.  She  said:  "It  was  like 
water.  I  was  going  down."  Or  again,  she  spoke 
of  having  gone  ^ ' under  the  ground " ;  "I  went  down, 
down  in  a  coffin."  She  spoke  of  having  gone  down 
*4nto  a  dark  hole,"  "down,  down,  up,  up";  again,  of 
having  been  "on  a  ship."  We  shall  see  in  the  fur- 
ther course  of  our  study  that  this  type  of  content 
occurs  not  at  all  infrequently. 

The  internal  relationship  among  the  different 
ideas  associated  with  stupor:  Before  we  go  any 
further  it  may  be  advisable  to  examine  the  meaning 
of  such  ideas  when  they  arise  in  other  settings  than 
those  of  the  psychoses.  If  we  consider  these  ideas 
of  death,  Heaven,  of  going  under  ground,  being  in 
water,  in  a  boat,  etc.,  we  are  impressed  with  the 
similarity  which  they  bear  to  certain  mythological 


IDEATIONAL   CONTENT   OF   THE   STUPOR    107 

motifs.  This  is,  of  course,  not  the  place  to  enter 
into  this  topic  more  than  briefly.  We  are  here  con- 
cerned with  a  clinical  study,  and  therefore,  among 
other  tasks,  with  the  interrelationship  of  symptoms, 
but  for  that  purpose  it  is  necessary  to  point  out  how 
these  ideas  seen  in  stupor  can  be  shown  to  have,  not 
only  a  connection  amongst  each  other,  when  viewed 
as  deep-seated  human  strivings,  but  also  are  closely 
related  to,  or  identical  with,  ideas  found  in  myth- 
ology. 

To  one's  conscious  mind  death  may  be  not  only 
the  dreaded  enemy  who  ends  life,  but  also  the  friend 
who  brings  relief  from  all  conflict,  strife  and  effort. 
Death  may,  therefore,  well  express  a  shrinking  from 
adaptation  and  reality,  and  as  such  may  symbolize 
one  of  the  most  deep-seated  yearnings  of  the  human 
soul.  But  from  time  immemorial  man  has  asso- 
ciated with  this  yearning  another  one,  one  which, 
without  the  adaptation  to  reality  being  made,  yet 
includes  a  certain  attempt  at  objectivation,  the  de- 
sire for  rebirth.  We  need  not  enter  further  into 
possible  symbols  for  death  per  se,  but  it  is  quite 
necessary  to  speak  briefly  of  the  symbolic  forms  in 
which  the  striving  for  rebirth  has  ever  found  expres- 
sion. The  reader  will  find  a  large  material  collected 
in  various  writings  on  mythology,  for  the  psycho- 
logical interpretation  of  which  reference  may  be 
made  to  Jun^\s  ''Wandlungen  und  Symbole  der 
Libido"  and  Rank's  ^'Mythos  von  der  Geburt  des 
Helden."  From  them  it  appears  how  old  are  the 
symbols  for  rebirth,  and  how  they  deal  chiefly  with 


108  BENIGN  STUPORS 

water  and  earth,  and  the  idea  of  being  surrounded 
by  and  enclosed  in  a  small  space.  Thus  we  find  a 
sinking  into  the  water  of  the  sea,  enclosure  in  some- 
thing which  swims  on  or  in  the  water,  such  as  a  cas- 
ket, or  a  basket,  or  a  fish,  or  a  boat;  again,  we  find 
descent  into  the  earth.  The  striving  for  rebirth 
might  be  assumed  to  have  adopted  these  expressions 
or  symbols  on  account  of  the  concrete  way  in  which 
the  human  mind  knows  birth  to  take  place.  The 
tendency  for  concrete  expression  of  abstract  notions 
causes  the  desire  for  another  existence  to  appear, 
first  as  a  rebirth  fantasy  and  then  as  a  return  to  the 
mother's  body.  One  thinks  of  Job's  cry,  *^ Naked 
came  I  from  my  mother's  womb  and  naked  shall  I 
return  thither,"  as  an  example  of  the  literal  com- 
parison of  death  with  birth.  "We  need  only  refer  to 
the  myths  of  Moses  and  the  older  one  of  Osiris,  and 
the  many  myths  of  the  birth  of  the  hero,  to  call  to  the 
mind  of  the  reader  the  examples  which  mythology 
furnishes.  There  is  probably  not  one  of  the  ideas 
expressed  by  these  patients  which  cannot  be  dupli- 
cated in  myths.  We  have,  therefore,  a  right  to  speak 
of  these  ideas  as  ''primitive,"  and  to  see  in  them, 
not  only  deep-seated  strivings  of  the  human  soul,  but 
to  recognize  in  them  an  essential  inner  relationship. 
It  is  especially  this  last  fact  to  which  at  this  point  we 
wish  to  call  attention :  that  without  any  obvious  con- 
nection the  fantasies  of  our  forefathers  recur  in  the 
delusions  of  our  stupor  cases.  We  presume  that  in 
each  case  they  represent  a  fulfillment  of  a  primitive 
human  demand.    In  one  of  our  cases  a  vision  of 


IDEATIONAL   CONTENT  OF  THE   STUPOR    109 

Heaven  and  a  conscious  longing  to  be  there  was  fol- 
lowed by  a  stupor.  On  recovery  the  patient  com- 
pared her  condition  to  that  of  a  butterfly  just 
hatched  from  a  cocoon.  No  clearer  simile  of  mental 
rebirth  could  be  given. 

Brief  survey  of  the  ideas  associated  with  the 
states  preceding  the  stupor:  If  we  now  return  to 
the  study  of  the  further  occurrence  of  such  ideas  in 
the  cases  described,  we  find  motifs,  similar  to  those 
seen  in  the  stupor,  in  the  period  which  immediately 
precedes  the  more  definite  stupor  reaction.  Indeed 
we  find  the  ideas  there  with  greater  regularity.  In 
Meta  S.  (Case  15)  the  stupor  followed  upon  six  days 
with  reduced  activity  and  crying,  with  self -accusa- 
tion, but  also  with  entreaties  to  be  allowed  to  go 
home  and  die  with  her  father.  At  the  very  onset  of 
her  breakdown,  the  desire  for  death  had  also  oc- 
curred. Anna  G.  (Case  1)  expressed  a  wish  to  be 
with  her  dead  father,  and,  at  the  visit  of  a  cousin, 
she  had  a  vision  of  the  latter 's  dead  mother.  A  sec- 
ond attack  of  this  same  patient  began  with  the  idea 
that  the  dead  father  was  calling  her.  Maggie  H. 
(Case  14)  saw  dead  bodies,  and  during  outbursts  of 
greater  anxiousness,  she  thought  her  husband  was 
going  to  die.  In  Caroline  De  S.  (Case  2)  the  psycho- 
sis began  with  a  coarse  excitement,  with  statements 
about  being  killed,  with  entreaties  to  be  shot,  with 
the  idea  of  going  to  Heaven,  again  with  frequent 
calling  out  that  she  loved  her  father  (who  was  dead 
since  her  ninth  year),  while  immediately  before  the 
stupor  the  condition  passed  into  a  muttering  state 


110  BENIGN  STUPORS 

in  which  she  spoke  of  being  killed.  Mary  D.  (Case 
4)  began  by  worrying  over  the  father ^s  death  (dead 
four  years  before),  had  visions  of  the  latter  beckon- 
ing, and  she  heard  voices  saying,  ''You  will  be 
dead."  Mary  F.  (Case  3)  had  a  vision  of  "a  person 
in  white,"  and  thought  she  was  going  to  die.  In 
Henrietta  H.  (Case  8)  the  stupor  was  preceded  by 
nine  days  of  elation,  with  ideas  of  shooting  and  of 
war,  but  this  had  commenced  with  hearing  voices 
of  dead  friends,  and  with  ideas  that  somebody 
wanted  to  kill  her  family.  In  the  case  of  Annie  K. 
(Case  5)  we  find  before  the  stupor  a  state  of  worry, 
with  reduction  of  activity,  and  then  a  vision  of  the 
dead  father  coming  for  her.  In  Charlotte  W.  (Case 
12)  the  stupor  was  preceded  by  a  state  of  preoccu- 
pation, with  distress  and  entreaties  to  be  saved, 
partly  from  being  put  into  a  big  hole,  partly  from 
the  electric  chair. 

We  see,  therefore,  in  the  introductory  phase  of  the 
stupor  in  almost  every  case  ideas  of  death,  and  in 
one  case  an  idea  belonging  to  the  rebirth  motif, 
namely,  of  being  put  into  a  dark  hole.  In  well-ob- 
served cases  apparently  we  do  not  find  the  stupor 
reaction  without  either  coincident  or  preceding  ideas 
of  death. 

Relation  of  death  and  rebirth  ideas  with  affect: 
In  order  to  investigate  the  relation  of  these  ideas  to 
the  affective  condition  associated  with  them,  it  will 
be  necessary  to  study  not  only  the  abstract  idea- 
tional content  but  the  special  formulation  in  which 
the  content  appears.    In  looking  over  the  enumera- 


IDEATIONAL   CONTENT  OF  THE   STUPOR    111 

tion  of  the  ideas  given  above,  it  is  very  clear  that 
these  formulations  differed  considerably  from  each 
other.  A  priori  we  would  say  that  it  is,  psychologi- 
cally, a  very  different  matter  whether  a  person  ex- 
presses a  desire  to  die,  or  has  the  idea  that  he  will 
die  or  is  dead,  or  says  he  will  be  killed.  We  asso- 
ciate the  first  with  sadness,  the  last  with  fear,  while 
our  daily  experience  does  not  give  us  so  much  infor- 
mation about  the  delusion  of  being  dead.  A  vivid  ex- 
pectation of  death  is  usually  accompanied  by  either 
fear  or  resignation. 

In  studying  the  ideas  which  we  obtained  from  the 
patients  by  retrospective  account  after  the  psychosis 
or  from  a  retrospective  account  during  freer  inter- 
vals, it  is,  of  course,  difficult,  especially  in  the  former 
case,  to  say  whether  they  have  persisted  for  any 
length  of  time.  Probably  in  most  instances  this  was 
not  the  case,  and  we  must  remember  in  this  connec- 
tion that  in  a  considerable  number  of  cases  the  pa- 
tients recalled  no  ideas  whatever. 

Of  the  five  cases  which  we  may  consider  as  types, 
Henrietta  H.  (Case  8)  and  Mary  F.  (Case  3)  formu- 
lated their  ideas  simply  as  accepted  facts  during  the 
stupor.  The  former  thought  she  was  dead,  saw  dead 
friends  laid  out  for  burial,  and  scenes  from  Heaven 
and  earth.  The  latter  spoke,  during  the  stupor,  of 
being  in  ^ '  Calvary, "  ' '  the  hereafter, ' '  or  ' '  Heaven. ' ' 
We  have  seen  that  these  stupors  were  essentially 
aifectless  reactions  and  we  can  therefore  say  that, 
so  far  as  these  two  cases  are  concerned,  the  ideas 
thus  formulated  were  not  associated  with  any  affect. 


112  BENIGN  STUPORS 

Annie  K.  (Case  5)  was  a  little  different.  During 
the  stupor  she  made  a  few  utterances  about  priests 
and  ''all  being  dead/'  and  retrospectively  she  said 
that  she  had  thought  she  was  in  the  cemetery,  was 
going  to  die,  that  she  had  repeated  visions  of  her 
dead  father  and  once  of  a  dead  aunt  calling  her ;  that 
she  had  thought  her  family  were  dead,  again  that 
the  baby  (who  was  born  just  before  the  psychosis) 
was  dead.  The  formulation  is  therefore  less  one  of 
fact  than  of  something  prospective,  something  which 
is  coming — the  going  to  die.  Correlated,  perhaps, 
with  this  anticipation  were  slight  modifications  of 
the  usual  apathy.  .  The  patient  often  had  an  expres- 
sion of  bewilderment.  She  was  also  more  in  contact 
with  her  environment  than  many  stuporous  patients 
are,  for,  not  infrequently,  she  would  look  at  what  was 
going  on  about  her. .  Her  apathy  was  also  broken 
into  in  a  marked  degree  by  her  active  resistiveness, 
which  was  sometimes  accompanied  by  plain  anger. 
It  seems  that  a  prospect  of  death  may  occur  in  other 
instances  in  a  totally  affectless  state.  We  have  re- 
cently seen  it  in  a  partial  stupor  during  which  the 
patient  spoke  and  had  this  persistent  idea  in  a  set- 
ting of  complete  apathy.  We  see  here  also,  as  in 
one  of  the  former  cases,  the  idea  of  other  members 
of  the  family  being  dead. 

More  difficult  and  deserving  more  discussion  are 
the  two  remaining  cases,  Eosie  K.  (Case  11)  and 
Charlotte  W.  (Case  12).  Eosie  K.  showed  a  pecu- 
liar condition.  She  said,  retrospectively,  that  during 
the  stupor  she  had  the  desire  to  die  and  that  for  this 


IDEATIONAL   CONTENT  OF  THE  STUPOR    113 

purpose  she  refused  food.  Moreover,  she  was  re- 
peatedly seen  to  hold  her  breath  with  great  insist- 
ence, though  without  affect.  This  is  worth  noting. 
We  are  in  the  habit  in  psychiatry  to  say  in  a  case 
like  this  that  ^*  there  is  no  atfect,''  and  yet  there  is 
evidently  a  considerable  ^*push"  behind  the  action. 
We  shall  later  have  to  mention  in  detail  a  patient 
whom  we  regard  as  belonging  in  the  group  of  stupor 
reactions,  and  who  for  a  time  made  insistent,  im- 
pulsive and  most  determined  suicidal  attempts,  yet 
with  a  peculiar  blank  affectless  facial  expression  and 
with  shouting  which  was  more  like  that  of  a  huckster 
than  one  in  despair.  Here  also,  then,  there  was  a 
great  deal  of  *^push,''  yet  not  associated  with  that 
which  we  call  in  psychiatry  an  affect.  In  both  in- 
stances we  see  acts  which  we  are  in  the  habit  of 
calling  for  this  very  reason  *' impulsive."  Evidently 
this  is  an  important  psychological  problem  which 
leads  directly  into  the  psychology  of  affects  and 
deserves  further  study.  For  the  present  it  is 
enough  to  say  that  with  a  different  formulation — 
that  of  wishing  to  die — there  is  here  not,  as  in  other 
psychoses,  a  definite  affect,  such  as  sadness  or  de- 
spair, but  no  affect,  though  there  may  be  a  good 
deal  of  *'push"  or  impulsiveness. 

The  case  of  Charlotte  W.  (Case  12)  is  a  compli- 
cated one,  for  she  had  short  stupor  periods  with 
inactivity,  catalepsy,  resistiveness,  etc.,  which  were 
interrupted  with  freer  spells.  A  careful  analysis  of 
her  historv  has  been  instructive  and  justifies  a  de- 
tailed and  lengthy  discussion.    For  the  purpose  in 


114  BENIGN  STUPORS 

hand  it  is  necessary  to  separate  the  ideas  which  she 
expressed  only  in  the  freer  periods  (during  which 
some  affect  was  at  times  seen)  into  those  which  re- 
ferred retrospectively  to  the  stupor  phase  and  those 
which  referred  to  the  freer  periods  themselves. 

We  find  that  the  time  during  which  more  marked 
stupor  symptoms  appeared  may  be  divided  into  two 
subperiods.  This  is  not  possible  in  regard  to  the 
manifestations  belonging  to  the  general  reaction, 
which  seem  to  have  undergone  no  decided  change, 
but  only  in  regard  to  the  form  of  the  delusions.  In 
this  we  find  there  was  a  first  phase  in  which  ideas  of 
death  and  Heaven  (and  crucifixion)  occurred,  and  a 
second  phase  in  which  ideas  were  present  which  be- 
longed essentially  to  the  motif  of  rebirth  but  which 
were  also  associated  with  ideas  of  Heaven. 

About  the  first  subperiod  she  said:  '*I  was  mes- 
merized,''  or  **I  thought  I  was  dead,'^  or  ''God  told 
me  I  must  die  on  the  cross  as  He  did,''  or  ''I  went 
to  Heaven  in  spirit.''  About  the  second  subperiod 
she  said  retrospectively:  ''We  were  on  a  ship  and 
we  were  'most  drowned."  "It  was  like  water,  I  was 
going  down,  down."  She  said  she  saw  the  people 
of  the  hospital  and  "it  was  all  full  of  water";  or 
again,  "I  went  under  the  ground  and  it  was  full  of 
water  and  every  one  got  drowned  and  a  sharp  thing 
struck  me";  or  "I  was  out  on  a  ship  and  I  went 
down  in  a  coffin. ' '  She  claimed  she  put  up  her  arms 
to  save  the  ship.  Again  she  spoke  of  having  gone 
into  a  dark  hole.  She  also  said:  "One  day  I  was 
in  a  coffin — that  was  the  day  I  went  to  Heaven." 


IDEATIONAL   CONTENT  OF  THE  STUPOR    115 

* '  They  used  to  be  coming  up  and  down,  that  was  the 
day  I  was  coming  up  in  a  ship  or  going  down. ' '  And 
when  shown  her  picture  in  a  cataleptic  attitude,  she 
said :  ' '  That  must  have  been  when  I  went  to  Heaven 
— everything  seemed  strange,  things  seemed  to  go 
up  and  down — I  guess  that  was  the  day  I  thought  I 
was  on  the  ship.''  Finally  she  also  said:  ^'Once  I 
heard  beautiful  music — I  was  waiting  for  the  last 
trumpet — I  was  afraid  to  move." 

We  see,  therefore,  that  most  of  the  ideas  which  she 
thus  spoke  of  retrospectively  as  having  been  in  her 
mind  during  this  stupor,  and  which  belonged  both 
to  the  death  and  the  rebirth  motifs  were  formulated 
as  facts  (as  in  the  cases  of  Henrietta  H.  and  Mary 
F.  above  mentioned).  It  was,  moreover,  a  condition 
which  was  accepted  without  protest.  Here  again  an 
affect  was  not  associated  with  these  ideas,  and  when 
the  patient  was  asked  whether  she  had  not  been 
frightened,  she  said  herself,  ^  ^  No,  I  just  lay  there. '  * 
The  idea  that  God  told  her  she  would  have  to  die  on 
the  cross  like  Christ,  is,  in  the  religious  form,  like 
the  beckoning  of  the  father  with  Henrietta  H.  The 
only  exception  to  the  claim  that  the  ideas  were 
formulated  as  facts  and  accepted  as  inevitable  seems 
to  be  the  statement  that  she  held  up  her  arms  to  save 
the  ship.  This  would  seem  to  be,  in  contradistinction 
to  the  rest,  a  formulation  as  a  more  dangerous  situa- 
tion. However,  this  was  isolated  and  we  can  do  no 
more  than  to  determine  main  tendencies.  We  must 
expect,  especially  in  such  variable  conditions  as  we 
see  in  this  patient,  to  find  occasional  inconsistencies. 


116  BENIGN  STUPORS 

In  summing  up  we  may  say,  therefore,  that  so  far 
as  the  stupor  itself  is  concerned,  the  ideas  are 
formulated  as  a  rule : — 

1.  As  accepted  facts  (being  dead,  being  in  a  ship, 
etc.). 

2.  As  accepted  prospects  (going  to  die). 

3.  As  the  wish  to  die. 

In  the  first  two  types  the  ideas  are  not  associated 
with  affect ;  in  the  third,  though  not  associated  with 
affect,  they  are  combined  with  ^ '  impulsive ' '  suicidal 
attempts. 

In  order  not  to  tear  apart  the  analysis  of  Char- 
lotte W.  (Case  12)  too  much,  we  may  begin  our  study 
of  the  intervals  and  the  conditions  preceding  the 
stupors  with  the  ideas  which  this  patient  produced 
when  the  stupor  lifted  somewhat.  We  shall  see  that 
the  ideas  are  closely  related  to  those  mentioned 
above  but  formulated  differently. 

It  will  be  remembered  that  Charlotte  W.  had  freer 
intervals  when  she  responded  and  was  less  con- 
strained generally,  and  that  it  was  in  these  that  the 
ideas  above  mentioned  were  gathered.  Since  they 
were  spoken  of  in  the  past  tense,  we  regarded  them 
as  not  belonging  to  the  actual  situation  but  to  the 
more  stuporous  period.  It  seems  tempting  now  to  see 
whether  the  ideas  which  are  expressed  in  the  present 
tense  are  different  in  character,  the  general  aim  be- 
ing to  discover  whether  any  tendencies  can  be  found 
in  regard  to  the  types  and  formulations  of  delusions 
associated  with  different  clinical  pictures.    We  see 


IDEATIONAL   CONTENT  OF  THE  STUPOR    117 

that  on  November  2  the  patient,  when  speaking  much 
more  freely  than  before,  said  she  had  felt  that  she 
was  mesmerized,  was  dead,  and  that  she  had  gone 
to  Heaven,  ideas  which  we  have  taken  up  above  as 
belonging  to  the  stupor  period.  In  addition  to 
speaking  much  more  freely  in  these  intervals,  she 
showed  at  times  some  affect.  Thus  to  the  physician 
whom  she  called  Christ,  she  said,  with  tears,  **You 
came  to  tell  me  what  was  right,''  or  again  with 
tears,  ' '  I  will  have  to  be  crucified, ' '  or  she  spoke  in 
a  depressed  maimer  about  her  children,  *'I  can't  see 
them  any  more,"  ^*I  must  stay  here  till  I  die,"  and 
she  spoke  of  having  to  stay  here  till  she  picked  her 
eyes  and  her  brains  out;  or  she  claimed  her  husband 
or  her  children  had  to  pick  them  out.  Once  she  ex- 
claimed crossly  and  with  tears,  **You  are  trying  to 
keep  me  from  Jim"  (husband).  Another  idea  was 
not  plainly  associated  with  affect.  She  said  she 
had  come  back  from  Heaven,  ^'The  wedding  ring 
kept  me  on  Earth."  What  strikes  one  about  these 
formulations  is  that  they  are,  on  the  one  hand,  some- 
times associated  with  an  affect,  and  that,  on  the 
other  hand,  they  refer  much  more  to  her  actual  life, 
her  marriage,  her  husband,  her  children.  At  least 
this  seems  to  be  a  definite  tendency.  A  similar  ten- 
dency may  be  seen  later :  On  November  4,  while  gen- 
erally stuporous,  this  suddenly  lifted  for  a  short 
time,  and  with  feeble  voice  she  uttered  some  depres- 
sive ideas.  She  said  she  wanted  to  go  to  a  convent, 
that  it  would  be  better  if  she  were  dead,  that  she 


118  BENIGN  STUPORS 

could  not  do  anything  right.  On  November  5  and 
6  she  said  she  wanted  to  go  to  Jim  in  Heaven  (in 
contradistinction  to  the  retrospective  statements 
that  she  had  gone  to  Heaven),  and  on  the  8th,  when 
she  had  the  idea  of  being  in  a  boat,  she  said  with 
some  anger  that  she  had  wanted  to  get  her  husband 
into  the  boat,  but  that  the  doctor  kept  him  out  and 
took  his  place. 

Later  there  were  at  times  ideas  expressed  which 
referred  to  the  actual  situation  or  essentially  depres- 
sive ideas  in  a  depressive  setting.  Thus  on  Decem- 
ber 3  she  appeared  sad,  retarded,  and  spoke  of  not 
being  able  to  see  her  children  and  that  she  had  done 
wrong  in  buying  carbolic  acid  (her  suicidal  attempt). 
So  far  as  this  case  is  concerned,  therefore,  we  do 
find  a  distinct  tendency  for  the  ideas  which  refer 
to  the  more  stuporous  condition  to  differ  from  those 
which  refer  to  the  actual  situation  in  the  freer  inter- 
vals, a  difference  which  we  may  formulate  by 
saying  that,  though  primitive  ideas  are  expressed, 
the  tendency  seems  to  be  to  connect  them  more  with 
actual  life,  or  that  the  primitive  character  is  lost 
and  the  ideas  take  on  a  more  depressive  character 
with  a  depressive  affect.  A  few  words  should  be 
added  in  regard  to  the  peculiar  ideas  that  she  or  her 
husband  or  her  child  had  to  pick  out  her  eyes  (or 
her  brain).  It  is  probable  that  this  idea  belongs 
to  the  motif  of  sacrifice  (the  Opfer  motiv  of  Jung) 
into  which  we  need  not  enter  further,  except  to  say 
that  in  this  instance  it  was  plainly  connected,  like 


IDEATIONAL   CONTENT  OF   THE   STUPOR    119 

some  of  the  other  ideas  just  spoken  of,  with  the  real 
situation  of  her  life  (husband,  children). 

It  will  now  be  necessary  to  examine  the  earlier 
state  of  Charlotte  W.  The  condition  preceding  the 
stupor  set  in  with  pre-occupation,  slow  talk  and 
slight  distress.  During  the  time  she  asked  to  be 
given  one  more  chance,  she  said  to  the  husband  she 
would  not  see  him  again.  Then  followed  a  day 
when  she  was  very  slow  and  with  moaning  said  she 
was  going  to  be  put  into  a  dark  hole.  Again  on  the 
next,  when  speaking  more  freely,  she  begged  to  be 
saved  from  the  electric  chair,  and  also  said,  '^ Don't 
kill  me,  make  me  true  to  my  husband,"  etc.  [Again 
the  connection  with  real  life!]  We  see  here  the 
idea  of  death  and  especially  an  idea  pertaining  to 
the  rebirth  motif  in  a  setting  of  distress  and  slow- 
ness, as  an  introduction  to  the  stupor  which  had  in  it 
both  of  these  motifs.  We  must  leave  it  undecided 
whether  it  is  accidental  or  not  that  the  distress  was 
associated  with  more  slowness  (i.  e.,  more  marked 
stupor  traits)  when  she  spoke  of  the  dark  hole  than 
when  she  spoke  of  the  electric  chair  or  death.  But 
what  interests  us  is  that  distress  and  reduction  of 
activity  (not  sadness  and  reduction  of  activity, 
which  seems  as  a  rule  to  have  a  different  content) 
are  here  associated  with  ideas  seen  in  stupor  but 
formulated  as  prospective  dangers.  We  know  from 
experience  that  we  often  find  associated  with  the 
fear  of  dying  considerable  freedom  of  action,  and 
we  see  at  times  in  involution  states  conditions  with 
freedom  of  motion  and  marked  anxiety,  whereas  the 


120  BENIGN  STUPORS 

ideas  seem  to  belong  to  the  motif  of  rebirtli;  e.  g., 
the  fear  of  being  boiled  in  a  tank.* 

In  this  connection,  however,  two  other  cases 
should  be  taken  up  which  show  a  condition  which  re- 
minds one  somewhat  of  that  we  have  just  discussed, 
but  in  which  the  rebirth  motif  appeared,  not  as  pro- 
spective, but,  as  in  the  stupor,  as  an  actual  situation. 
At  the  same  time  this  situation  was  not  passively 
accepted  but  conceived  as  a  dangerous  situation. 
The  significant  phenomenon  in  both  these  conditions 
was  that  there  was  not  anxiety  with  freedom  of  ac- 
tion but  a  bewildered  uneasiness  with  marked  reduc- 
tion of  activity. 

The  first  case  is  that  of  Johanna  S.,  whose  his- 
tory has  been  given  in  this  chapter.  It  will  be  ob- 
served that  in  the  fourth  period  the  patient  pre- 
sented two  days  of  typical  stupor  with  the  idea  that 
she  was  dead.  We  are  familiar  with  this.  But  this 
was  followed  by  several  days  of  bewildered  uneasi- 
ness and  slow  restlessness,  with  ideas  that  she  was 
at  the  bottom  of  the  deep,  dark  water  and  for  a  time 
she  made  attempts  at  stepping  out  of  the  water  or 
swimming  motions.  All  of  this  was  in  a  general 
setting  of  reduction  of  activity  with  bewildered  un- 
easiness. In  the  ideas  about  being  at  the  bottom 
of  the  deep,  dark  water,  we  recognize  again  the  re- 

*  We  may  mention  that  since  this  study  was  made  we  risked  a 
prediction  of  stupor,  which  events  justified,  in  the  case  of  a  patient 
who  showed  expectation  of  death  without  affect.  Such  opportuni- 
ties are  rare,  however,  since  we  usually  do  not  see  these  cases  till 
the  stupor  symptoms  are  manifest.  It  would  be  unsafe  to  dogma- 
tize on  the  basis  of  such  meager  material. 


IDEATIONAL   CONTENT  OF  THE  STUPOR    121 

birth  motif,  yet  the  situation  is  not  accepted  but 
attempts  are  made  by  the  patient  to  save  herself, 
i.  e.,  the  attitude  is  one  in  which  the  situation  is  taken 
to  be  one  of  danger.  It  is  interesting  in  this  con- 
nection that  immediately  following  this  state  there 
was  one  day  of  ordinary  retardation  with  sadness 
and  ideas  of  being  bad  and  sick.  That  is,  when  the 
element  of  anxiety,  the  uneasiness,  disappeared  and 
sadness  supervened,  the  rebirth  ideas  were  no 
longer  present. 

In  Mary  C.  (See  Chapter  II,  Case  7)  we  have,  un- 
fortunately, not  a  direct  observation,  but  we  have, 
at  any  rate,  a  description  from  the  Observation  Pa- 
vilion which  seems  so  plain  that  we  should  be  jus- 
tified in  using  it  here.  The  condition  we  refer  to  is 
described  as  a  dazed  uneasiness,  with  ideas  of  being 
shut  up  in  a  ship,  of  the  ship  being  closed  up  so  that 
no  one  could  get  out,  of  the  boat  having  gone  down, 
of  the  people  turning  up.  We  should  add  here  that 
the  condition  was  not  followed  by  a  typical  stupor. 
Essentially  it  was  a  retardation,  in  which  only  on 
one  occasion  was  a  definite  akinesis  observed.  Dur- 
ing this  phase  she  soiled  her  bed.  Perhaps  the  per- 
sistent complaint  of  inability  to  take  in  the  environ- 
ment belonged  also  more  to  the  retardation  of  stupor 
than  to  that  of  depression.  We  have  again,  there- 
fore, in  this  initial  phase,  a  similar  situation, 
namely,  ideas  belonging  essentially  to  the  rebirth 
motif,  formulated  as  of  a  threatening  character  if 
not  as  actually  dangerous. 

We  can  say,  therefore,  that  what  characterizes 


122  BENIGN  STUPORS 

these  three  cases,  and  brings  them  together,  is  the 
fact  that  all  three  had  ideas  belonging  to  the  rebirth 
motif,  but  formulated  as  dangerous  situations.  As- 
sociated with  this  there  was  not  a  typical  anxiety 
with  the  relative  freedom  of  activity  belonging  to 
this  state,  but  an  anxiety  or  distress  or  uneasiness 
with  traits  of  stupor  reaction,  namely,  slow  move- 
ments, lack  of  contact  with  the  environment,  and  a 
dazed  facial  expression.  It  would  seem  that  these 
facts  could  scarcely  be  accidental  but  that  they 
must  have  a  deeper  significance.  As  a  discussion 
of  this  belongs,  however,  more  into  the  psychological 
part  of  this  study,  we  shall  defer  it  for  the  present, 
and  be  satisfied  with  pointing  out  here  the  clinical 
facts  of  observation. 

In  brief,  then,  our  findings  as  to  the  ideational 
content  of  the  benign  stupor  are  as  follows :  From 
the  utterances  during  the  incubation  period  of  the 
psychosis,  from  the  ideas  expressed  in  interruptions 
of  the  deep  stupor,  as  well  as  from  the  memories 
of  recovered  patients,  we  find  an  extraordinary  pau- 
city and  uniformity  of  autistic  thoughts.  They  are 
concerned  with  death,  often  as  a  plain  delusion  of 
being  no  longer  alive,  or  with  the  closely  related 
fancy  of  rebirth.  The  rule  is  a  setting  of  apathy 
for  these  ideas,  but  when  they  are  formulated  so  as 
to  connect  them  with  the  real  life  and  problems  of 
the  patient,  or  when  rebirth  is  represented  as  a 
dangerous  situation,  some  aifect,  usually  one  of  dis- 
tress, may  appear. 


CHAPTER  VI 
AFFECT 

The  most  constant  and  significant  symptom  in  tlie 
stupor  reaction  is  the  change  in  affect.  This  ex- 
tends from  mere  quietness  in  the  mildest  phases  of 
the  disease  through  the  stage  of  indifference  where 
apathy  replaces  the  normal  reactions  of  the  person- 
ality, to  the  final  condition  of  complete  inactivity 
in  the  vegetative  stupor  where  all  mental  life  seems 
to  have  ceased.  It  seems  as  though  there  were,  as 
a  pathognomonic  sign  of  the  morbid  process,  a  lack 
of  energy  and  loss  of  the  normal  elan  vital. 

We  may  say,  in  fact,  that  the  establishment  of  a 
specific  type  of  emotional  change  is  justification  for 
classifying  all  milder  stupor  reactions  with  the  deep 
stupors.  In  other  words,  our  reason  for  the  en- 
largement of  the  stupor  group  to  include  all  apa- 
thetic reactions  (except  those  of  dementia  prsecox) 
is  the  belief  that  this  dulling  of  the  emotional  re- 
sponse is  as  specific  a  type  of  emotional  change  as 
is  anxiety,  depression  or  elation.  Perhaps  it  would 
be  more  accurate  to  say  that  this  clinical  group  is 
founded  on  the  symptom  complex  which  is  built 
around  apathy.  There  is  never  any  resemblance 
between  apathy  and  the  mood  of  elation  or  anxiety. 

123 


124  BENIGN  STUPORS 

A  discrimination  from  depression  is  the  only  dif- 
ferentiation worth  discussion. 

The  first  point  that  should  be  made  is  that  there 
is  a  difference  between  marked  depression  and  the 
mood  of  stupor.  In  the  former  we  get  a  retardation 
with  a  feeling  of  blocking,  rather  than  of  an  absence 
of  energy.  The  expression  of  the  patient  is  one 
of  dejection,  not  of  vacancy,  which  bespeaks  a  mood 
of  sadness,  even  when  the  patient  is  so  retarded  as 
to  be  mute  and  therefore  incapable  of  describing  his 
emotions.  Eunning  through  all  the  stages  of  stupor, 
however,  there  is  an  emptiness,  an  indifference  that 
is  in  striking  contrast  to  the  positive  pain  that  is  felt 
or  expressed  by  the  depressed  patient.  It  may  be 
objected,  of  course,  that  this  apathy  really  repre- 
sents the  final  stage  in  the  emotional  blocking  of 
the  depressed  individual,  but  the  development  of 
stupor  and  recovery  from  it  shows  an  entirely  dif- 
ferent type  of  process.  A  deep  depression  recovers 
by  changing  the  point  of  view  from  a  feeling  of  un- 
worthiness  and  self -blame  to  one  of  normality.  The 
stuporous  case,  on  the  other  hand,  evidences  merely 
less  and  less  indifference,  and  more  and  more  inter- 
est in  his  environment  and  in  himself  as  he  gets 
well. 

The  associated  symptoms  are  no  less  dissimilar. 
The  difiSculty  in  thinking  which  troubles  the  de- 
pressed patient  is  slight  in  proportion  to  his  emo- 
tional gloom,  and  he  feels  himself  to  be  much  more 
incompetent  intellectually  than  examination  proves 
him  to  be.     On  the  other  hand,  in  the  stupor  reac- 


AFFECT  125 

tion  we  find  that  the  thinking  disorder  runs  hand 
in  hand  with  the  apathy  and  that  the  intellectual 
capacity  of  the  patient  is  really  markedly  interfered 
with,  as  can  be  shown  by  more  or  less  objective  tests. 
A  mere  slowing  of  thought  processes  accompanied 
by  subjective  feeling  of  effort  is  the  limit  reached 
in  true  depression,  while  it  is  merely  the  beginning 
of  the  intellectual  disorder  in  stupor,  for  one  meets 
with  retardation  symptoms  only  in  the  partial  stu- 
pors. The  slowing  in  these  cases  seems  to  represent 
an  early  stage  of  the  intellectual  disturbance  which 
reaches  its  acme  in  the  mental  vacuity  and  com- 
plete incompetence  of  the  deep  stupor,  just  as  slow 
movements  in  the  partial  stupors  seem  to  represent 
a  diluted  inactivity  reaction.  This  actual  thinking 
disorder  is  not  present  in  those  forms  of  manic- 
depressive  insanity  which  are  characterized  by  ela- 
tion, anxiety  or  depression  but  is  seen  only  in  stu- 
pors, occasionally  in  absorbed  manic  states  (manic 
stupor)  and  sometimes  in  perplexity  states.  The 
psychological  mechanisms  of  this  last  group  are 
probably  analogous  to  those  of  stupor,  but  this  is 
not  the  place  for  a  discussion  of  this  topic. 

Another  associated  symptom  whose  manifesta- 
tions differ  in  depression  and  stupor  is  that  of  un- 
reality. In  the  former  there  is  frequently  a  feeling 
of  unreality  that  is  purely  subjective,  whereas  the 
stupor  case  does  not  usually  complain  of  this  but 
does  exhibit  a  difficulty  in  grasping  the  nature  of 
his  environment,  which  the  typical  depressive  case 
never  has. 


126  BENIGN  STUPORS 

The  occurrence  of  other  mood  reactions  than 
apathy  in  the  same  patient  is  also  characteristic. 
Manic  states  (usually  hypomanic)  frequently  occur 
during  the  phase  of  recovery  from  the  stupor.  This 
is  an  unusual,  although  not  unknown,  phenomenon 
in  recovery  from  severe  retarded  depressions.  The 
circular  cases  who  swing  from  depression  to  elation 
usually  show  the  milder  types  of  depressive  reaction 
which  would  never  be  confused  with  stupor.  On 
the  other  hand,  deep  stupors  very  frequently  are 
terminated  by  manic  reactions,  and  if  not  by  such 
means,  recovery  seems  to  occur  merely  in  virtue  of 
a  gradual  attenuation  of  the  stupor  symptoms. 
Earely  do  we  see  a  change  to  depression  or  anxiety 
heralding  improvement.  This  tendency  of  the  stu- 
por reaction  to  remain  pure  or  change  to  hypomania 
is  a  peculiarity  which  seems  to  put  stupor  in  a  class 
by  itself  among  the  manic-depressive  reactions,  as 
all  the  other  mood  reactions  frequently  change  from 
one  to  the  other. 

Although  apathy  is  the  central  pathognomonic 
symptom  of  stupor  conditions,  there  are  other  mood 
anomalies  to  be  noted.  One  of  these  is  the  tendency 
for  inconsistency  in,  as  well  as  reduction  of,  the  ex- 
pression of  emotion.  For  instance,  in  the  states 
where  one  would  expect  anxiety  during  the  onset 
of  stupor  or  in  its  interruptions,  manifestation  of 
this  anxiety  is  often  reduced  to  an  expression  of 
dazed  bewilderment.  In  the  anxiety  states  asso- 
ciated with  stupor  one  does  not  meet  with  the  rest- 
lessness and  expressions  of  fear  which  would  be  ex- 


AFFECT  127 

pected.  Quite  similarly,  when  a  manic  tendency  is 
present,  it  occurs  either  in  little  bursts  of  isolated 
symptoms  of  elation  (such  as  smiling  or  episodic 
pranks),  or  some  of  the  evidences  of  elation  which 
we  would  expect  are  missing.  For  instance,  Jo- 
hanna S.  (Case  13)  terminated  her  stupor  with  a 
hypomanic  state  which  was  natural  except  for  her 
always  wearing  an  expressionless  face.  Sometimes 
laughter  occurs  alone  and  gives  the  impression  of  a 
shallow  affect,  raising  a  suspicion  of  dementia  prae- 
cox.  In  fact,  such  evidences  of  affect  as  do  appear 
in  the  course  of  the  stupor  are  apt  to  be  isolated, 
queer  and  ' '  dissociated. ' '  It  does  not  seem  as  if  the 
whole  personality  reacted  in  the  emotion  as  it  does 
in  the  other  forms  of  manic-depressive  insanity. 
For  example,  we  may  think  of  the  resistiveness 
which  is  so  frequently  present  when  the  patient 
seems  in  other  respects  to  be  psychically  dead.  One 
may  recall  the  case  of  Meta  S.  (Case  15),  who,  other- 
wise inert,  was  occasionally  seen  with  tears  or  smiles. 
Anna  G.  (Case  1),  too,  was  often  seen  smiling  or 
weeping.  It  was  noted  once  of  Charlotte  W.  (Case 
12)  that  she  ceased  answering  questions  and  re- 
mained immobile  with  fixed  gaze,  but  when  some 
mention  was  made  of  her  going  home  she  flushed 
and  tears  ran  down  her  cheeks,  although  no  change 
in  the  fixedness  of  her  attitude  or  facial  expression 
was  seen.  "When  Johanna  S.  was  visited  by  her 
daughter  and  was  lying  motionless  in  bed,  she 
slowly  extended  her  hands,  apparently  tried  to 
speak,  and  then  her  eyes  filled  with  tears.    Two  days 


128  BENIGN  STUPORS 

later,  at  the  end  of  an  interview  when  she  had  made 
a  few  replies,  she  settled  down  into  her  usual  inac- 
tivity and,  when  further  urged  to  answer,  her  eyes 
filled  with  tears.  Similarly,  too,  in  fairly  deep  stu- 
por pin  pricking  may  result  in  flushing,  in  tears  or 
an  increased  pulse  rate  without  the  patient  giving 
any  other  evidence  of  the  stimulus  being  felt.  These 
examples  seem  to  show  a  larval  effort  at  normal  hu- 
man response  which,  failing  of  complete  expression, 
appeared  as  single  isolated  features  of  emotion  sug- 
gesting true  dissociation.  We  should  also  in  this 
connection  bear  in  mind  the  impulsive  suicidal  acts 
which  occur  either  as  unexpectedly  as  the  impulsive- 
ness in  a  true  dementia  prsecox  patient,  or  in  a  set- 
ting of  coarse  animal-like  excitement  that  seems 
quite  unrelated  to  the  personality.  One  is  reminded 
of  the  patient  who  made  suicidal  attempts  during 
the  period  when  she  shouted  like  a  huckster,  giving 
no  evidence  whatever  by  her  expression  or  the  tone 
of  her  voice  of  feeling  anxiety,  sorrow  or  any  other 
normal  emotion. 

All  these  queer  and  larval  affective  reactions  re- 
mind one  strongly  of  dementia  prsecox.  The  resem- 
blance of  the  benign  stupor  to  certain  dementia  prse- 
cox types  is  not  merely  a  matter  of  identity  with 
catatonic  features  (catalepsy,  negativism).  In 
these  anomalous  mood  reactions  it  seems  as  if  there 
were  a  definite  dissociation  of  affect,  and  so  there  is. 
How  then  can  we  differentiate  these  emotional  symp- 
toms from  the  **  dissociation  of  affecf  which  is  re- 
garded as  a  cardinal  symptom  of  dementia  praecox? 


AFFECT  129 

The  answer  is  that  this  term  is  used  too  loosely  as 
applied  to  the  latter  psychosis.  It  is  a  particular 
type  of  dissociation  which  is  significant  of  the  schiz- 
ophrenic reaction,  for  in  it  there  is  an  acceptance 
of  what  should  be  painful  ideas  evidenced  either  by 
incomplete  manifestations  of  anxiety  or  depression 
or  actually  by  smiling.  We  never  see  in  dementia 
prsecox  the  reverse — a  painful  interpretation  of 
what  would  normally  be  pleasant.  It  is  the  pleas- 
urable interpretation  of  what  is  really  unpleasant 
that  gives  the  impression  of  queerness  in  the  mood 
of  these  deteriorating  or  chronic  cases.  In  stupor, 
on  the  other  hand,  although  this  dissociation  takes 
place,  the  mood  is  never  inappropriate,  merely  in- 
complete in  that  all  the  components  or  the  full  ex- 
pression of  the  normal  reaction  are  not  seen. 

Our  description  of  the  mood  reactions  in  stupor 
would  be  incomplete  if  we  omitted  to  mention  the 
occasional  appearance  of  an  emotional  attitude  not 
unlike  that  seen  in  many  cases  of  involution  melan- 
cholia, whidh  reminds  one  in  turn  of  the  reactions 
of  a  spoiled  child.  The  commonest  of  these  mani- 
festations is  resistiveness  that  may  occur  when  an 
examination  is  attempted,  feeding  is  suggested,  or  a 
sanitary  routine  insisted  upon.  One  also  meets 
with  resentfulness.  One  patient,  who  frequently 
showed  this  reaction,  explained  it  retrospectively  by 
saying  that  she  wanted  to  be  left  alone.  Quite  analo- 
gous to  this  is  sulkiness  that  occasionally  appears. 
Then  we  have,  particularly  as  recovery  begins,  other 
childish  tricks,  such  as  flippancy  in  answering  ques- 


130  BENIGN  STUPORS 

tions  or  the  playing  of  pranks.  Such  tendencies 
naturally  lead  over  to  frank  hypomanic  behavior. 

Finally,  a  peculiar  characteristic  of  the  stupor 
apathy  must  be  mentioned.  This  is  its  tendency  to 
interruptions,  when  the  patient  may  return  to  life, 
as  it  were,  for  a  few  moments  and  then  relapse. 
Such  episodes  occur  mainly  in  milder  cases  or  to- 
wards the  end  of  long,  deep  stupors.  It  is  interesting 
that  the  occasion  for  such  reappearance  of  affect  is 
frequently  obvious.  We  usually  observe  them  in  re- 
sponse to  some  special  stimulus,  particularly  some- 
thing that  seems  to  revive  a  normal  interest.  Visits 
of  relatives  are  particularly  common  as  such  stimuli, 
in  fact  recovery  can  often  be  traced  to  the  appear- 
ance of  a  husband,  mother  or  daughter.  It  is  also 
important  to  recognize  that  with  this  revived  inter- 
est, other  clinical  changes  may  be  manifest,  that  the 
thinking  disorder  may,  for  instance,  be  temporarily 
lifted.  Helen  M.,  for  example,  when  visited  by  her 
mother  was  so  far  awakened  as  to  take  note  of  her 
environment,  and  remembered  these  visits  after  re- 
covery like  oases  in  the  blank  emptiness  of  her  stu- 
por. She  further  remembered  that  definite  ideas 
were  at  such  a  time  in  her  mind  that  ordinarily  was 
vacant.  She  then  had  delusions  of  being  electro- 
cuted. 

In  summary,  then,  we  may  say  that  the  sine  qua 
non  of  the  stupor  reaction  is  apathy  in  all  grada- 
tions, and  that  this  apathy  is  as  distinct  a  mood 
change  as  is  elation,  sorrow  or  anxiety.  Incidental 
to  this  loss  of  affect  there  is  a  dissociation  of  emo- 


AFFECT  131 

tional  response  whereby  isolated  expressions  of 
mood  appear  without  the  harmonious  cooperation  of 
the  whole  personality  which  seems  to  be  dead. 
Thirdly,  there  tends  to  be  associated  with  the  stupor 
reaction  a  tendency  to  childish  behavior.  Finally, 
the  apathy  and  accompanying  stupor  symptoms  may 
be  suddenly  and  momentarily  interrupted.  An  ex- 
planation of  these  apparently  anomalous  phenomena 
will  be  attempted  in  the  chapter  on  Psychology  of 
the  Stupor  Eeaction. 


CHAPTEEVII 
INACTIVITY,  NEGATIVISM  AND  CATALEPSY 

1.  Inactivity.  We  must  now  turn  our  attention  to 
the  other  cardinal  symptoms  of  the  stupor  reaction, 
and  quite  the  most  important  one  of  these  is  the 
inactivity.  It  is  convenient  to  include  under  this 
heading  both  the  reduction  of  bodily  movement  and 
the  diminution  or  absence  of  speech.  This  inactiv- 
ity is,  of  course,  related  to  the  apathy  which  we  have 
just  been  discussing,  in  fact  it  is  one  of  the  evidences 
of  the  loss  of  emotion.  We  presume  that  a  patient 
is  apathetic  when  there  is  no  expression  in  the  face 
and  when  he  does  not  respond  to  external  stimuli, 
whether  these  be  physical  or  verbal,  by  movement 
or  by  word. 

Bodily  inactivity  is  present  in  all  degrees,  and  in 
some  forty  consecutive  cases  was  recognizable  in 
every  one.  In  its  most  extreme  form  there  is  com- 
plete flaccidity  of  all  the  voluntary  muscles,  and 
relaxation  of  some  sphincters.  As  a  result  of 
the  latter  we  see  wetting,  soiling  and  drooling. 
Even  those  reflexes  whidh  are  only  partially  under 
voluntary  control,  like  those  of  blinking  and  swal- 
lowing, may  be  in  abeyance ;  for  instance,  saliva  may 
collect  in  the  mouth  because  it  is  not  swallowed,  and 

132 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  133 

tube-feeding  is  frequently  necessary  on  account  of 
the  failure  of  the  patient  to  swallow  anything  that  is 
put  into  his  mouth.  The  eyes  may  remain  open  for 
such  long  periods  of  time  that  the  conjunctiva  and 
sclera  may  become  quite  dry  and  ulcerate.  In  these 
extreme  cases  there  is,  of  course,  no  response  to 
verbal  commands.  What  is  more  striking,  no  reac- 
tion appears  to  pin  pricks,  so  that  it  seems  as  if  con- 
sciousness of  pain  were  lost. 

This  deep  torpor  does  not  usually  persist  indefi- 
nitely. The  commonest  evidence  of  some  form  of 
consciousness  persisting  is  probably  to  be  seen  in 
blinking  when  the  eye  is  threatened  or  the  sclera  or 
cornea  actually  touched.  A  very  large  number  of 
patients,  when  otherwise  quite  inactive,  showed  con- 
siderable response  in  their  muscular  resistiveness, 
the  phenomena  of  which  will  be  discussed  shortly. 
The  relaxation  of  the  sphincters  is  apt  to  persist 
even  after  control  of  the  rest  of  the  body  is  exercised 
to  the  point  of  permitting  the  patient  to  stand  or 
walk  about. 

The  first  phase  of  obvious  conscious  control  is 
seen  in  those  patients  who  will  retain  a  sitting  pos- 
ture in  bed  or  in  a  chair.  The  next  stage  is  reached 
where  the  stuporous  case  can  be  stood  upon  his  feet 
but  cannot  be  induced  to  walk.  The  next  degree  is 
that  of  walking  only  when  pushed  or  commanded. 
Finally  spontaneous  movement  is  observed  in  which 
the  inactivity  is  evidenced  merely  by  a  great  slow- 
ness. 

No  correlation  can  be  established  between  restric- 


134  BENIGN  STUPORS 

tions  o±  speech  and  motion  other  than  that  present 
in  the  extremes.  With  complete  inactivity  there  is  al- 
most always  consistent  mutism,  and  perfect  freedom 
of  speech  does  not,  as  a  rule,  appear  until  the  move- 
ments are  free,  in  between  these  extremes  all  va- 
riations are  possible,  even  the  deepest  stupors  are 
occasionally  interrupted  by  one  or  two  words;  for 
instance,  a  patient  may  remain  comatose,  as  it  were, 
and  absolutely  mute  for  six  months,  then  to  every 
one 's  surprise  say  one  or  two  words  and  relapse  into 
a  year  of  silence.  Again  one  sees  cases  where  move- 
ments have  become  fairly  free  and  yet  the  patient 
says  nothing.  This  is  another  example  of  that  in- 
consistency in  reaction  which  we  have  already  noted 
in  connection  with  the  mood  or  affect. 

In  so  far  as  inactivity  is  merely  an  expression  of 
apathy,  its  causation  will  be  considered  in  connection 
with  the  psychology  of  the  stupor  reaction  as  a 
whole.  In  so  far  as  there  may  be  specific  factors, 
however,  it  may  be  of  interest  to  consider  what  in- 
formation the  patients  themselves  give  us  from  time 
to  time  as  to  what  determined  their  inactivity.  It 
is  really  surprising  how  frequently  something  can 
be  gained  either  from  careful  notes  taken  during  the 
stupor  or  from  the  retrospective  accounts  of  the 
psychotic  experiences.  Of  course  when  one  consid- 
ers the  degree  of  amnesia  which  is  usually  present 
and  the  extent  of  the  intellectual  defect  in  general, 
it  becomes  obvious  that  one  cannot  think  of  getting 
anything  like  a  complete  explanation  of  the  behavior 
of  any  given  case.     Nevertheless  this  material  is 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  135 

quite  suggestive  in  the  mass ;  it  gives  one  some  idea 
of  the  mental  state  as  a  whole. 

Among  40  cases,  27  offered  some  explanation 
either  during  or  following  the  psychosis.  Of  these, 
20  spoke  of  feeling  dead,  numb  or  drugged,  or  feel- 
ing as  if  paralyzed  or  having  lockjaw.  This  group, 
just  half  of  all  the  cases,  apparently  ascribed  their 
disability  to  something  which  seemed  physical. 
One  might  call  them  somatopsychic  cases.  The 
other  7  gave  more  allopsychic  explanations :  3  at- 
tributed their  inactivity  to  outside  influence ;  3  more 
said  they  were  afraid  (one  of  these  because  she  imag- 
ined herself  to  be  in  prison),  which  is  analogous  to 
the  outside  influence ;  the  7th  case  thought  she  would 
injure  people  if  she  moved. 

The  following  are  some  examples  of  the  state- 
ments of  the  somatopsychic  group:  Laura  A.:  ^*I 
can't  move,"  and  retrospectively,  **My  arms  were 
stiff.''  Bridget  B.  claimed  retrospectively  that  she 
felt  dead  or  drugged,  that  her  limbs  were  lifeless, 
she  felt  as  if  she  had  lockjaw.  Johanna  B.  remem- 
bered being  pricked  with  a  pin  on  several  occasions 
hat  claimed  that  she  did  not  feel  the  pain  at  any 
time.  This  suggests  a  definitely  hysterical  mecha- 
nism. Anna  L.  (Case  16)  said  retrospectively  that 
she  felt  as  if  she  were  dead,  although  walking 
around,  and  also  that  she  thought  she  was  a  ghost 
and  not  supr)0sed  to  speak.  Anna  M.  said  she  had 
tried  to  sr>eak  but  evervthins:  stuck  in  her  throat. 
Alice  T?;.  said  that  she  had  no  enersr,  did  not  want  to 
talk.    Meta  S.  (Case  15)  claimed  that  while  stupor- 


136  BENIGN  STUPORS 

ous  her  tongue  would  not  move.  Isabella  M.  in  in- 
tervals claimed  that  during  the  stuporous  periods 
she  felt  as  if  dead  and  said  retrospectively  when 
the  whole  psychosis  was  over  that  it  was  ^ '  an  effort 
to  speak.'*  Johanna  S.  (Case  13),  while  stuporous 
when  pressed  with  questions  would  say:  *^I  can't 
think,"  **I  don't  know,"  ^'I  am  twisted."  When 
food  was  offered  her  she  protested,  *^I  am  dead." 
Charlotte  W.  (Case  12),  in  reviewing  her  case,  said: 
'*I  was  mesmerized,"  *'I  thought  I  was  dead." 
Anna  G.  (Case  1),  in  retrospect  said:  ^^I  don't  think 
I  could  speak,"  again  ^^I  made  no  effort,"  or  ^*I  did 
not  care  to  speak."  Henrietta  H.  (Case  8)  said,  **I 
lost  speech."  She  claimed  that  she  did  not  move 
because  she  was  tired  and  had  a  numb  feeling. 
Mary  C.  (Case  7)  said  that  her  tongue  had  been  thick 
and  that  she  felt  dull.  Eose  Sch.  (Case  6)  said  dur- 
ing the  psychosis  that  her  head  was  upside  down 
and  retrospectively  that  she  had  been  mixed  up, 
could  not  remember  well,  did  not  feel  like  talking. 
Mary  D.  (Case  4)  said  that  she  had  been  dazed,  that 
she  had  not  felt  like  talking,  and  that  her  limbs 
*  *  were  stiff  like. ' '  We  should  probably  also  include 
here  as  a  delusion  of  death  the  statement  of  Annie 
K.  (Case  5)  who  wanted  to  die  and  thought  she  would 
do  so  if  she  kept  still  enough. 

It  is  rather  striking  that  amonsr  all  the  forty  cases 
only  one  spoke  of  being  sick — **I  am  so  sick."  Only 
one  evaded  questions  with  ''that  was  my  illness." 
One  would  expect  a  priori  that  these  patients  would 
offer  some  vague  explanations  or  make  complaints 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  137 

of  weakness.  If  these  stupors  were  purely  physical 
in  origin,  one  would  expect  such  explanations  as 
weakness  or  illness  to  be  ottered  in  accounting  for 
the  inactivity.  That  there  is  a  rather  dehnite  type 
of  explanation  oif  ered  is,  we  think,  distinctly  sug- 
gestive. If  one  tries  to  correlate  and  group  the 
death  ideas,  one  sees  that  they  are  all  delusions  of 
death  or  of  loss  of  energy  or  complaints  of  hysteri- 
cal symptoms  that  look  like  sham  death.  If  the 
lack  of  energy  complained  of  be  looked  upon  as  lif  e- 
lessness,  one  can  conceive  of  these  explanations  be- 
ing variations  of  one  theme,  namely,  that  of  death. 
In  the  last  chapter  it  has  been  shown  that  a  delu- 
sion of  dying,  being  dead,  or  having  been  dead  is 
extremely  frequent  in  the  stupor  group.  It  would 
seem  only  natural  then  to  regard  the  inactivity,  in 
so  far  as  it  may  be  specifically  determined,  as  an  ex- 
pression of  some  such  delusion. 

Psychiatrists  are  more  or  less  aware  of  there  be- 
ing typical  ideational  contents  in  the  different 
manic-depressive  psychoses.  For  instance,  every 
one  is  familiar  with  ideas  of  wickedness  and  inade- 
quacy in  depression,  ideas  of  violence  in  anxiety,  or 
expansive  and  erotic  fancies  in  manic  states.  Quite 
similarly  we  have  seen  that  death  is  a  dominant 
topic  in  a  stupor.  Now  in  addition  to  these  typical 
ideas  we  often  hear  expressed  what  we  might  term 
non-specific  delusions,  ideas  that  seem  to  have  noth- 
ing to  do  with  a  peculiar  type  of  reaction  which  the 
patient  presents.     It  is  therefore  not  surprising  to 


138  BENIGN  STUPORS 

find  that  inactivity  is  not  consistently  ascribed  to 
death  or  a  related  delusion. 

For  instance,  Henrietta  B.  had  much  talk  of  higher 
powers  that  were  controlling  her,  also  said  that 
it  was  fear  which  kept  her  quiet.  J  osephine  Gr.  said 
retrospectively  that  she  had  thought  she  would  in- 
jure people  if  she  moved  and  that  if  she  opened  her 
eyes  she  would  murder  the  people  around  her.  Jo- 
hanna B.  was  afraid  to  talk  because  she  fancied  she 
was  in  prison.  Laura  A.:  During  her  stupor  was 
more  vague,  saying,  ''I  can't  move,  they  won't  let 
me  be,"  without  betraying  any  suggestion  of  whom 
''they"  might  be.  Finally  Mary  C.  (Case  7)  was 
still  more  indefinite,  ascribing  her  immobility  merely 
to  fear.  When  one  considers,  however,  that  these 
^ve  were  the  only  ones  who  gave  any  atypical  ex- 
planation of  their  inactivity  among  the  thirty-seven 
cases,  the  preponderance  of  the  death  idea  becomes 
striking. 

2.  Negativism.  The  next  of  the  cardinal  symptoms 
to  be  considered  is  negativism.  This  term,  which  is 
often  loosely  used,  we  would  define  as  perversity  of 
behavior  which  seems  to  express  antagonism  to  the 
environment  or  to  the  wishes  of  those  about  the 
patient.  Naturally  it  is  only  in  the  minor  stupors 
that  we  see  it  in  well-developed  form  as  active  oppo- 
sition and  cantankerousness.  For  example,  Har- 
riett C,  who  stood  about  until  her  feet  became 
edematous,  would  spit  out  food  when  it  was  placed 
in  her  mouth  but  would  eat  if  she  were  left  alone 
with  the   food.     Josephine   G.,  in  a  milder   state, 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  139 

would  turn  her  back  on  people.  Wlien  more  inactive 
once  rolled  out  of  bed  and  lay  on  the  floor.  At  this 
time  also  she  tried  to  keep  people  out  of  her  room. 
Rarely,  patients  may  have  angry  outbursts,  as  did 
Annie  K.  (Case  5)  who  would  strike  at  the  nurses. 

Very  often  the  failure  to  swallow  and  anomalous 
habits  of  excretion  seem  to  be  negativistic  in  their 
nature.  One  thinks  at  once  of  the  necessity  for  tube- 
feeding,  which  is  so  coromon  even  when  patients 
seem  otherwise  fairly  active.  Naturally  this  form 
of  treatment  is  necessary  only  when  the  patient  re- 
fuses to  swallow.  Quite  frequently  a  refusal  to 
urinate  is  met  with  so  that  catheterization  is  neces- 
sary, or  a  patient  may  never  use  the  toilet  when 
led  to  it,  but  will  defecate  or  urinate  so  soon  as  he 
leaves  it.  These  latter,  like  some  other  perversities, 
suggest  reactions  of  a  petulant,  spoiled  child. 

By  far  the  commonest  manifestation  is  muscular 
resistiveness,  often  spoken  of  as  ^^resistiveness." 
It  was  present  in  thirty-two  out  of  thirty-seven  of 
our  cases.  Usually  it  takes  the  form  of  a  contrac- 
tion of  the  whole  system  of  voluntary  muscles  when 
the  patient  is  touched  or  the  bed  approached.  Often 
it  appears  only  when  any  passive  movement  of  the 
limb  is  attempted.  All  muscles  of  the  limb  then 
stiffen,  making  the  member  rigid.  Sometimes  the 
negativism  is  expressed  by  quite  isolated  symptoms, 
such  as  stiffness  in  the  jaw  muscles  alone.  One  pa- 
tient showed  no  opposition  except  bv  holding  her 
urine  for  two  days.  Another  kept  her  eyes  con- 
stantly directed  to  the  floor.     The  reaction  of  an- 


140  BENIGN  STUPORS 

other  showed  no  irregularity  except  for  stiffness  in 
the  neck  and  arms  and  wetting  herself  once  after 
she  had  been  taken  to  the  toilet.  One  displayed 
merely  a  slight  stiffness  in  her  arms.  An  interest- 
ing case  was  that  of  Annie  G.  (Case  1)  who  kept 
one  leg  sticking  out  of  bed.  If  this  were  pushed 
in,  she  would  protrude  the  other.  Mary  F.  (Case 
3)  sometimes  expressed  her  antagonism  to  the  en- 
vironment by  slapping  other  patients.  She  spoke 
only  twice  in  a  year  and  a  half,  and  each  time  it  was 
when  interfered  with.  By  far  the  commonest  cause 
of  muscular  movement  in  these  inactive  cases  is  re- 
sistiveness,  and  as  a  rule  the  inactivity  is  interrupted 
only  by  negativistic  symptoms. 

If  we  look  for  some  explanation  or  correlation  of 
these  symptoms,  we  find  that  chance  references  to 
conduct  seem  to  point  in  the  same  direction,  namely, 
to  the  desire  to  be  left  alone.  This  resentment 
against  interference  again  reminds  us  of  the  reac- 
tions of  a  spoiled  child.  For  instance,  Laura  A.,  in 
manic  spells  during  which  she  was  still  constrained 
and  drooled,  said,  **I  don't  want  to  have  my  face 
washed.'*  In  the  intervals  she  showed  an  intense 
muscular  resistiveness.  Mary  G.  used  to  say,  **  Leave 
me  alone,"  and  covered  her  head  or  buried  it  in 
the  pillows.  Maggie  H.  (Case  14)  said  in  retrospect 
that  she  had  wanted  to  be  left  alone.  Similarly  Alice 
R.  thought  she  did  not  want  to  talk.  Emma  K. 
thought  that  she  was  in  prison  and  apparently  re- 
sented this.  Henrietta  B.  combined  in  her  behavior 
tendencies    both    to    compliance    and    opposition. 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  141 

When  her  arms  were  raised  they  retained  the  new 
position  for  a  minute.  Then  she  dropped  them  and 
said,  ^'Stop  mesmerizing  me.''  But  then  she  put 
them  up  again  of  her  own  accord,  and  when  she  had 
done  this  presented  intense  resistiveness  to  any 
movement.  Later  she  extended  her  arms  in  front 
of  her  and  said,  '^I  am  all  right,"  in  a  theatrical 
manner,  and  then  added,  ^'Why  don't  you  go 
away?" 

There  seems  to  be  some  correlation  between  inac- 
cessibility and  muscular  resistiveness.  For  exam- 
ple, Charlotte  W.  (Case  12),  whose  condition  varied 
a  great  deal,  always  lost  the  resistiveness  when  she 
became  accessible,  during  which  periods  she  also 
showed  some  facial  expression.  The  resistiveness 
would  invariably  return  when  the  inaccessibility 
reappeared.  Caroline  DeS.  (Case  2)  lost  her  resis- 
tiveness as  she  became  more  accessible,  although  the 
inactivity  and  apathy  persisted.  This  tendency, 
which  is  quite  common,  suggests  that  muscular  re- 
sistiveness represents  a  lower  level  of  expression  of 
opposition  which  patients  put  into  words  or  pur- 
poseful actions  when  there  is  other  evidence  of  some 
contact  with  the  environment.  Sometimes  one  ob- 
serves both  general  resistiveness  and  specific  acts. 
For  instance,  Mary  G.,  who  said,  ** Leave  me  alone," 
and  covered  her  head  or  buried  it  in  the  pillows, 
accompanied  her  muscular  resistiveness  with  laugh- 
ter. This  shows  the  affective  nature  of  the  appar- 
ently purposeless  muscular  tension.  The  case  of 
Annie  K.  (Case  5)  is  more  instructive.    In  the  stage 


142  BENIGN  STUPORS 

of  deeper  stupor  she  had  the  automatic  type  of  re- 
sistiveness  but  also  outbursts  of  anger,  particularly 
toward  the  nurses;  striking  one  of  them  she  said, 
^'You  are  the  cause  of  it  all/'  When  food  was  of- 
fered her,  she  said, ' '  I  wonder  people  would  not  leave 
me  alone  sometimes. ' '  Again,  when  her  bed  was  ap- 
proached, she  would  clutch  and  hold  the  bed  clothes 
in  an  apparently  aimless  way  as  if  the  impulse  to 
resist  never  reached  its  goal.  Eetrospectively  she 
could  not  account  for  her  muscular  rigidity  on  the 
basis  of  definite  ideas,  and  could  recall  only  that 
she  felt  stubborn.  In  a  later  period  when  more  ac- 
cessible, she  felt  cross  and  did  not  want  to  be  both- 
ered. This  emotional  attitude  was  quite  conscious 
with  her,  whereas  the  acts  and  speech  of  the  earlier 
period,  when  her  stupor  was  more  profound,  seemed 
more  automatic  and  impulsive.  In  other  words,  the 
resistiveness  looks  like  a  larval  attempt  to  express 
an  idea  which  is  probably  not  fully  conscious  and 
therefore  gives  the  appearance  of  being  aimless. 
As  another  example  of  this  we  may  cite  the  case  of 
Pearl  F.  (Case  9),  who  said  when  she  recovered,  *^I 
was  stubborn."  In  addition  to  the  muscular  resis- 
tiveness she  had  shown,  she  would  often  bite  the  bed 
clothes  or  scratch  herself  when  she  was  approached. 
Mary  F.  (Case  3),  while  in  a  stupor,  slapped  at 
nearby  patients  quite  aimlessly.  When  somewhat 
better,  this  conduct  appeared  in  a  more  conscious 
form,  as  sullenness,  indifference  and  smearing  of 
feces  (again  the  behavior  of  a  naughty  child).  Here 
one  might  quote  Laura  A.  once  more,  whose  resis- 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  143 

tiveness  when  stuporous  was  intense  but  who  in  her 
manic  spells  expressed  her  negativism  in  a  definite 
idea,  "I  don't  want  my  face  washed." 

To  summarize,  then,  we  may  say  that  negativism 
is  apparently  the  result  of  a  desire  to  be  left  alone, 
and  that  muscular  resistiveness  is  a  larval  exhibition 
of  the  same  tendency.  But  the  appearance  of 
this  attitude  in  such  aimless,  impulsive  acts  or 
habits  reminds  us  strongly  of  the  dissociation  of 
affect,  which  was  commented  on  in  the  previous 
chapter.  It  would  seem  to  be  another  example  of 
this  rather  fundamental  tendency  of  the  stupor  re- 
action, not  merely  to  diminish  conative  reactions  in 
general,  but  to  reduce  their  appearance  to  that  of 
isolated,  partial  and  therefore  rather  meaningless 
expression. 

3.  Catalepsy.  The  last  of  the  cardinal  symptoms 
to  be  considered  is  catalepsy.  It  occurred  in  thirteen 
of  thirty- seven  cases,  although  it  was  present  only 
as  a  tendency  in  three  of  these.  If  we  define  it  as 
the  maintenance  of  position  in  which  a  part  of  the 
body  is  placed  regardless  of  comfort,  we  can  see  that 
sometimes  it  is  difficult  to  differentiate  from  the 
phenomenon  of  resistiveness  with  its  rigidity.  It  is 
most  frequently  observed  in  the  hands  and  arms, 
perhaps  because  it  is,  as  a  rule,  most  convenient 
to  demonstrate  the  retention  of  awkward  positions 
in  the  upward  extremities.  But  any  jDart  or  even 
the  whole  body  may  be  involved;  for  example, 
Charles  0.  retained  standing  positions  even  where 
balance  was   difficult.     This  phenomenon   is   often 


144  BENIGN  STUPORS 

accompanied  by  *^waxy  flexibility,"  where  the  joints 
move  stiffly  but  retain  whatever  bend  is  given  them, 
like  a  doll  with  stiff  joints. 

The  significance  of  catalepsy  is  best  studied  by 
considering  its  relationship  to  other  symptoms  and 
by  noting  remarks  made  by  the  patients  in  reference 
to  it.  The  most  important  observations  which  we 
have  made  seem  to  indicate  that  it  never  occurs  with 
that  degree  of  deep  inactivity  which  suggests  a  com- 
plete lack  of  mentation  on  the  part  of  the  patient. 
One  is  therefore  forced  to  conclude  that  back  of  this 
phenomenon  there  must  be  some  purpose,  some  kind 
of  an  ideational  content,  although  this  may  be  of  a 
primitive  order.  This  is  demonstrably  true  in  some 
cases,  at  least  such  as  that  of  Isabella  M.,  who  left 
her  arm  sticking  up  in  the  air  but  took  it  down  to 
scratch  herself  and  then  put  it  back.  Somewhat 
similarly,  Charlotte  W.  (Case  12),  when  she  was 
shown  during  convalescence  a  photograph  of  herself 
in  a  cataleptic  state,  said  that  that  was  when  she  was 
waiting  to  go  to  Heaven  and  was  afraid  to  move. 
Again  she  remarked,  *^I  was  mesmerized.''  Jo- 
sephine Gr.,  who  showed  only  a  tendency  to  catalepsy, 
said  that  she  feared  the  devil  would  get  control  of 
those  about  her  if  she  moved.  Sometimes  there  is 
a  development  of  this  symptom  from  others  which 
seem  to  be  ideational  in  their  origin.  For  instance, 
Charles  0.  began  making  flail-like  movements. 
These  passed  over  into  slow  circular  motions  which 
finally  subsided  into  the  maintenance  of  fixed  po- 
sition. 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  145 

Eeferences  to  hypnotism  are  not  infrequent,  and 
in  many  cases  there  is  evidence  of  a  delusion  that 
the  posture  is  desired  by  those  in  charge  of  the 
patient.  Annie  G.  (Case  1)  said  so  directly.  In 
retrospect  she  explained  the  holding  of  her  arms  in 
the  air  by  saying,  ^ '  I  thought  you  wanted  me  to  have 
them  up."  Henrietta  B.  at  one  examination  kept 
her  arms  raised  in  the  position  in  which  they  had 
been  put  for  a  minute  and  then  dropped  them,  say- 
ing, ^'Stop  mesmerizing  me.'^  But  she  then  put 
them  up  again  of  her  own  accord  and  now  presented 
intense  resistance  to  any  motion.  Later  she  ex- 
tended her  arms  in  front  of  her  and  said,  **I  am  all 
right,"  in  a  theatrical  manner.  Some  patients  give 
evidence  in  other  symptoms  of  larval  efforts  at  co- 
operation with  the  actual  or  supposed  wishes  of  the 
physician  and  in  such  cases  it  is  not  impossible  that 
passive  movements  are  interpreted  as  orders.  One 
must  remember  in  this  connection  that  the  more 
primitive  are  the  mental  operations  of  any  indi- 
vidual, the  more  important  do  signs,  rather  than 
speech,  come  to  be  a  medium  of  communication  with 
other  people.  As  an  example  of  this  type  we  might 
mention  Eose  Sch.  (Case  6),  who  flinched  from  pin 
pricks  (showing  that  she  felt  them)  but  made  no 
effort  to  get  away.  When  somewhat  clearer  she  said 
that  she  was  ^^here  to  be  cured."  Similarly  Mary 
D.  (Case  4),  who  showed  no  catalepsy  from  ordinary 
tests,  kept  her  head  off  the  pillow  for  a  long  time 
after  it  was  raised  to  have  her  hair  dressed.  She 
showed  such  perseveration  in  many  constrained  po- 


146  BENIGN  STUPORS 

sitions.  She  too  flinched  from  pin  pricks  but  not 
only  made  no  effort  to  prevent  them  but  would  even 
stick  out  her  tongue  to  have  a  pin  stuck  in  it. 

The  relationship  of  catalepsy  to  resistiveness  is 
interesting  but  unfortunately  complicated  and  un- 
clear. In  only  one  of  our  cases  was  catalepsy  defi- 
nitely present  without  resistiveness,  and  in  one 
other  a  ^'tendency  to  catalepsy"  was  noted  without 
muscular  rigidity  being  observed.  In  this  latter 
case,  when  the  catalepsy  became  unquestionable, 
resistiveness  also  appeared.  It  is  one  thing  to  note 
this  coexistence  and  another  to  explain  it  ade- 
quately. All  that  we  can  offer  are  mere  speculations 
as  to  the  real  meaning  of  the  association  of  these 
phenomena.  It  may  be  that  the  tension  of  muscles 
that  occurs  when  resistiveness  is  present  gives  the 
idea  to  the  patient  of  holding  the  position.  There 
would  be  two  possible  explanations  for  this.  We 
might  think  there  is  a  dissociation  of  consciousness, 
like  that  of  hysteria,  where  the  feeling  of  tenseness 
in  the  muscles  that  comes  from  the  resistance  to 
gravity  is  not  discriminated  from  the  resistance  to 
the  movements  made  by  the  examiner.  On  the  other 
hand,  there  might  be  a  similar  dissociation  where 
the  perception  of  contraction  in  the  antagonistic 
muscles  is  interpreted  as  the  action  of  the  examiner 
in  placing  the  limb  in  a  given  position.  This  latter 
view  would  seem,  on  the  face  of  it,  ridiculous,  inas- 
much as  its  presumes  the  existence  of  two  directly 
opposed  tendencies,  namely,  those  of  opposition  to 
the  will  of  the  physician  and  compliance  with  it.  But 


INACTIVITY,  NEGATIVISM  AND   CATALEPSY  147 

ambivalent  tendencies  are  frequently  present  in 
psychopathic  states,  and  moreover  we  find  occasion- 
ally some  evidence  in  the  behavior  of  the  patient 
to  substantiate  this  view.  For  example,  at  one  stage 
of  the  stupor  of  Annie  Gr.  (Case  1),  her  arm  could  be 
moved  without  r^stance.  Then  the  elbow  would 
catch  and  at  this  moment  the  position  would  be 
maintained.  Such  observation  is  highly  suggestive 
of  the  resistance  being  signal  for  the  catalepsy.  In 
Isabella  M.  the  catalepsy  appeared  when  resistance 
to  passive  movements  also  developed.  On  the  other 
hand,  when  the  resistance  became  extreme,  the  cata- 
lepsy was  reduced,  and  vice  versa.  This  makes  one 
think  of  two  tendencies ;  suggestibility  on  the  one 
hand,  and  opposition  on  the  other.  We  might  pre- 
sume that  when  both  are  present  and  equally  strong, 
stiffness  with  passive  movements  results  as  a  kind 
of  compromise,  but  when  there  is  a  greater  develop- 
ment of  one,  the  other  is  inhibited. 

Such  speculations  remind  one  strongly  of  the 
psychology  of  conversion  hysteria  and  of  hypnotism. 
In  some  cases  of  stupor  hysterical  symptoms  are 
quite  definitely  present.  For  instance,  Celia  Gr. 
began  her  psychosis  with  hysterical  convulsions 
which  would  terminate  with  short  periods  of  stupor. 
Later  the  stupor  became  persistent  and  during  this 
stage  she  had  catalepsy  (and  restiveness  as  well) 
in  her  left  arm  only.  On  recovery  from  her  stupor 
she  complained  of  stiffness  in  her  hands,  which 
examination  proved  to  be  a  purely  hysterical  diffi- 
culty. 


148  BENIGN  STUPORS 

This  whole  subject  is  without  question  obscure 
and  many  more  and  very  careful  observations  are 
needed  before  really  satisfactory  explanations  can 
be  given  for  these  phenomena.  That  it  is  a  reaction 
which  is  related  to  the  primitiveness  of  the  mental 
content  and  the  intellectual  deficit  in  stupor  would 
seem  to  be  a  reasonable  view,  inasmuch  as  quite 
similar  phenomena  have  been  observed  in  a  large 
number  of  animals,  even  among  crustaceans.  As  a 
result  of  our  own  observations  the  only  thing  we 
feel  at  liberty  to  state  with  real  confidence  is  that 
catalepsy  is  presumably  a  phenomenon  mental  in 
origin  rather  than  somatic,  because  it  always  occurs 
in  conditions  which  show  other  evidence  of  menta- 
tion. 

Whatever  may  be  the  origin  of  the  idea  of  the 
posture  assumed,  there  can  be  little  doubt  that  its 
indefinite  maintenance  is  a  phenomenon  of  persev- 
eration. The  conception  of  the  position  being  in 
the  patient's  mind,  it  is  easier  to  hold  it  than  elabo- 
rate another  idea.  This,  of  course,  is  part  of  the 
intellectual  disorder  in  stupor.  In  fact,  it  is  difficult 
to  imagine  any  one  whose  critical  faculty  was  func- 
tioning cooperating  in  a  test  for  catalepsy. 


CHAPTER  VIII 

SPECIAL  CASES:  RELATIONSHIP  OF  STUPOR  TO 
OTHER  REACTIONS 

We  have  described  typical  cases  of  benign  stupor 
and  isolated  certain  interrelated  symptoms  which, 
when  they  dominate  the  clinical  picture,  we  believe 
establish  the  diagnosis  of  stupor,  regardless  of  the 
severity  of  the  reaction.  These  symptoms  are 
apathy,  inactivity,  a  thinking  disorder  and,  quite  as 
important  as  these,  an  absorbing  interest  in  death. 
It  is  typical  that  the  patient  contemplates  his  disso- 
lution with  indifference  or,  at  most,  with  mild  or 
sporadic  anxiety.  There  seems  little  reason  to  doubt 
that  when  these  four  symptoms  occur  alone,  we  are 
justified  in  making  a  diagnosis  of  stupor.  The  next 
problem  is  to  consider  the  meaning  and  classification 
of  cases  where  these  symptoms  occur  in  conjunction 
with  others.  This  naturally  introduces  the  subject 
of  relationship  of  stupor  to  other  manic-depressive 
reactions. 

It  is  probably  best  to  begin  with  presentation  of 
three  such  cases. 

Case  16. — Anna  L.  Age:  24.  Admitted  to  the  Psychiatric 
Institute  Augnst  21,  1916. 

F.  II.  Maternal  grandmother  temporarily  insane  during  il- 
legitimate pregnancy,  thereafter  a  little  odd.     Mother  high  strung 

149 


150  BENIGN  STUPORS 

and   emotional.      Father   high   strung,    impulsive    and    irritable. 

P.  H.  As  a  child  she  was  quick  tempered,  quite  a  spitfire  and 
given  to  tantrums.  At  the  age  of  14  she  became  a  vaudeville 
actress  in  Cleveland,  which  was  the  home  of  her  childhood. 
When  17  she  married  a  Jew,  although  she  was  herself  a  Catholic. 
Her  husband  noted  that  she  was  fretful,  sensitive,  resentful  and 
quick  tempered,  although  apt  to  recover  quickly  from  her  rages. 
Previously  healthy,  neurotic  symptoms  began  with  marriage,  tak- 
ing the  form  of  stomach  trouble  and  a  tendency  to  fatigue. 
Shortly  after  marriage  an  abortion  was  induced.  After  being 
married  for  two  years  she  had  a  quarrel  and  separated  from  her 
husband.  They  were  reconciled  later,  but  in  the  meantime  she 
had  been  having  relations  with  another  man.  When  20  an  ab- 
dominal operation  was  performed  in  the  hope  of  relieving  her 
gastric  symptoms,  but  no  improvement  occurred.  The  patient 
after  recovery  stated  that  she  continued  to  be  nervous,  shaky  and 
dizzy,  at  times  trembling  when  going  to  bed  at  night.  Two  years 
later,  however,  she  took  up  Christian  Science  and  showed  objec- 
tively some  improvement  in  her  health,  although  according  to  her 
later  accounts  she  continued  to  feel  somewhat  nervous  and  fatigu- 
able.  Her  husband  stated  that  at  this  time  she  also  began  to 
ponder  much  about  such  questions  as  the  difference  between  life 
and  death,  what  "matter"  was,  and  also  studied  "grammar"  and 
"etiquette."  According  to  the  patient  some  five  or  six  months 
before  admission  she  began  to  have  peculiar  sensations  following 
intercourse — a  feeling  of  bulging  in  the  arms,  legs  and  back  of  the 
neck.  One  evening  after  an  automobile  ride  there  were  peculiar 
sensations  on  her  right  side  like  "electricity"  or  as  if  she  were 
inhaling  an  anesthetic.  She  gasped  and  thought  she  was  dying. 
Two  months  before  her  admission  she  went  with  her  husband  and 
his  family  to  a  summer  resort  where  she  felt  increasingly  what 
had  always  been  a  trouble  to  her,  namely,  the  nagging  of  this 
family. 

Just  before  her  breakdown,  because  she  went  daily  to  the 
Christian  Science  rooms  in  order  to  avoid  the  family,  they  sus- 
pected her  of  immorality  and  accused  her  of  going  to  meet  other 
men.  Even  her  husband  began  to  question  her  motive.  Retro- 
spectively the  patient  herself  said  that  she  now  felt  she  was  losing 
her  mind  and  did  not  wish  to  talk  to  any  one.    At  the  time  she 


SPECIAL  CASES  151 

told  her  husband  that  she  felt  confused  and  as  if  she  were  guilty 
of  something-  and  being  condemned.  Repeatedly  she  said  she 
knew  she  was  going  to  get  the  family  into  a  lot  of  trouble.  Once 
she  spoke  of  suicide,  and  for  a  while  felt  as  if  she  were  dying. 
Finally  she  became  excited  and  shouted  so  much  that  she  was 
taken  to  the  Observation  Pavilion,  where  she  was  described  as 
being  restless  and  noisy,  thinking  that  she  was  to  be  burned  up 
and  that  she  had  been  in  a  fire  and  was  afraid  to  go  back. 

On  admission  she  looked  weary  and  seemed  drowsy.  Questions 
had  to  be  repeated  impressively  before  replies  could  be  obtained, 
when  she  would  rouse  herself  out  of  this  drowsy  state.  She 
seemed  placid  and  apathetic.  She  said  that  nothing  was  the 
matter,  but  soon  admitted  that  she  had  not  been  well,  first  saying 
that  her  trouble  was  physical  and  then  agreeing  that  it  had  been 
mental.  When  asked  whether  she  was  happy  or  sad,  she  said 
"happy,"  but  gave  objectively  no  evidence  of  elation.  Her 
orientation  was  defective.  She  spoke  of  being  in  New  York  and 
on  BlackwelFs  Island,  but  could  not  describe  what  sort  of  place 
she  was  in,  saying  merely  that  it  was  "a  good  place,"  or  "a  nice 
country  place,"  again  "a  good  city."  Once  when  immediately 
after  her  name  L.  had  been  spoken  and  she  was  asked  what  the 
place  was,  she  said  "The  L."  She  knew  that  she  had  arrived  in 
the  hospital  that  day  but  said  that  she  had  come  from  Cleveland, 
and  to  further  questions,  that  she  had  come  by  train,  but  she 
could  not  tell  how  she  reached  the  Island.  She  claimed  not  to 
know  what  the  month  was  and  guessed  that  the  season  was  either 
spring  or  autumn  (August).  She  gave  the  year  as  1917,  called 
the  doctor  "a  mentalist,"  and  the  stenographer  "a  tapper,"  or 
"a  mental  tapper."  She  twice  said  she  was  single.  When  asked 
directly  who  took  care  of  her,  said  "Mr.  Marconi,"  who  she 
claimed  at  another  time  had  brought  her  to  the  hospital.  To  the 
question,  who  is  he?  she  replied,  "Wireless,"  and  could  not  be 
made  to  explain  further.  That  night  she  urinated  in  her  bed, 
and  later  lay  quite  limp,  again  held  her  legs  very  tense. 

For  five  days  she  remained  lying  quietly  in  bed  for  the  most 
part,  although  once  she  called  out  "Come  in,  I  am  here,"  "Jimmie, 
Jimmie"  (husband's  name).  Several  times  she  threw  her  bed 
clothes  off.  Otherwise  she  made  no  attempt  to  speak  and  took 
insufficient  food  unless  spoon-fed.  At  one  examination  she  looked 
up   rather   dreamily    but    did   not    answer.     When   shaken    she 


152  BENIGN  STUPORS 

breathed  more  quickly  and  seemed  about  to  cry ,  but  made  no 
effort  to  speak.  When  left  to  herself  she  closed  her  eyes  and 
did  not  stir  when  told  she  could  go  back  to  the  ward.  She  was 
then  lifted  out  of  her  chair  and  took  a  step  or  two  and  stopped. 
Such  urging  had  to  be  repeated,  as  she  would  continue  to  remain 
standing,  looking  about  dreamily,  although  finally  when  taken 
hold  of  she  whimpered.  When  she  got  to  the  dining-table  she 
put  her  hand  in  the  soup  and  then  looked  at  it.  So  far  there  is 
nothing  in  this  case  atypical  of  what  we  would  call  a  partial 
stupor.  The  cardinal  symptoms  of  apathy,  inactivity,  with  a 
thinking  disorder,  are  all  present  and  dominate  the  clinical  pic- 
ture. There  is,  further,  the  history  of  a  delusion  of  death  during 
the  onset  of  the  psychosis.  Had  her  condition  remained  like  this, 
there  would  be  no  difficulty  in  classifying  the  case,  but  other 
symptoms  appeared. 

Five  days  after  admission  she  was  restless,  somewhat  distressed, 
and  announced  that  she  wanted  to  talk  to  the  physician.  When 
examined,  the  distress,  with  some  whimpering,  continued.  She 
asked  the  doctor  not  to  be  harsh  to  her,  frequently  said  there  was 
something  wrong  and  began  to  cry.  A  normal  interest  appeared 
only  once,  when  she  spontaneously  said  she  wanted  to-  see  her 
relatives.  A  most  interesting  feature,  however,  was  a  certain 
perplexity  that  now  appeared.  She  spoke  of  this  directly :  "I  do 
not  know  what  it  is  all  about.  I  know  you  are  a  doctor,  that  is  all. 
I  don't  know  whether  I  passed  out  and  came  back  again  or 
what — I  don't  know  what  to  make  of  it."  She  also  felt  confused 
about  her  marriage — "There  is  where  all  the  mixup  is.  I  was 
married  when  I  was  16."  She  was  reminded  that  she  had  said 
she  was  single,  and  replied  "I  am  single."  Then  where  is  your 
husband?  she  was  asked.  "He  must  be  dead."  She  recalled  the 
examination  on  admission  and  remembered  some  of  the  questions 
that  she  was  asked  then,  also  knew  that  she  had  been  at  the 
Observation  Pavilion  and  that  she  had  reached  this  hospital  by 
boat.  On  the  other  hand  she  still  claimed  that  the  year  was  1917, 
and  in  connection  with  the  delusion  of  having  died  was  quite 
unclear  as  to  the  time.  She  said  that  it  seemed  as  if  she  had 
died  many  years  ago  and  that  she  had  come  to  the  hospital  years 
ago.  She  also  spoke  of  having  died  at  a  summer  resort  the  year 
before.    When  asked  for  her  age,  she  said  that  she  must  be  very 


SPECIAL  CASES  153 

old,  but  on  the  other  hand  claimed  that  she  was  supposed  to  die 
and  to  come  to  the  hospital  when  she  was  26  (two  years  more 
than  her  actual  age). 

Her  psychosis  continued  from  then  on  for  about  ten  weeks. 
She  soon  began  to  feed  herself,  but  otherwise  for  most  of  this 
period  remained  quietly  in  bed,  looking  about  a  good  deal, 
although  showing  no  particular  mood  reaction  until  questioned, 
when  she  was  apt  to  make  repeated  statements  about  her  per- 
plexity— that  she  did  not  know  what  it  was  all  about,  every  one 
had  mixed  her  up,  everything  was  so  strange,  "my  head  is  mixed 
up,  I  am  trying  to  straighten  things  up."  She  frequently  when 
interviewed  became  lachrymose  and  often  with  her  subjective 
confusion  there  was  considerable  anxiety.  Another  unusual 
phenomenom  for  a  stupor  patient  was  that  she  was  frightened 
at  a  thunder  storm.  On  the  whole,  however,  her  apathy  and 
indifference  were  quite  marked.  For  instance,  during  the  latest 
phase  of  her  psychosis,  when  the  nurses  would  sometimes  make 
her  dance  with  them,  she  did  so  but  without  showing  any  interest 
and  not  until  immediately  before  her  recovery  did  she  begin  to 
speak  spontaneously  to  any  extent  whatever.  A  marked  difference 
from  the  ordinary  stupor  was  that  this  apathy  was  invariably 
broken  into  when  she  was  questioned  and  ideas  came  to  her  mind, 
the  nature  of  which  seemed  to  be  essentially  connected  with  her 
perplexity. 

Not  only  did  ideas  appear  more  frequently  than  one  meets 
them  in  stupor  cases,  but  they  were  present  in  greater  variety. 
The  dominant  stupor  death  idea  was,  it  is  true,  almost  constantly 
present,  but  it  did  not  come  to  the  direct  and  unequivocal  ex- 
pression which  we  are  accustomed  to  see  in  typical  stupor.  She 
did  not  say  "I  am  dead,"  or  "I  was  dead,"  but  it  was  always 
"It  seems  as  if  I  were  dead,"  or  "1  think  I  must  have  died,"  or 
some  such  dubious  statement.  Other  ideas  were  that  her  mother 
was  dead  and  had  been  put  into  a  box.  She  frequently  gave  her 
maiden  name  and  said  that  she  lived  in  Cleveland  with  her  mother 
and  that  this  was  Cleveland.  At  times  she  thought  she  was  en- 
gaged and  was  going  to  be  married  to  her  husband  shortly. 
Again  there  were  notions  that  her  husband  had  married  somebody 
else  or  that  some  harm  was  going  to  come  to  him.     Sometimes 


154  BENIGN  STUPORS 

she  thought  that  her  mother's  name  was  her  own,  that  is,  Mrs.  L. 
The  hospital  once  seemed  like  a  convent  to  her. 

Her  subjective  and  objective  confusion  seemed  quite  definitely 
to  be  connected  with  the  insecurity  and  changeability  of  these 
ideas.  It  appeared  as  if  insight  and  delusion  were  struggling 
for  mastery  in  her  mind,  so  that  reality  and  fancy  were  alter- 
nately, even  simultaneously,  possessing  her,  and  that  this  gave  her 
the  feeling  of  perplexity  from  which  she  suffered.  Once  when 
she  remarked  "It  seems  as  if  I  had  been  dead  all  the  time,"  she 
was  questioned  more  about  this  and  replied,  "Well,  sometimes  I 
thought  I  was  dead,  at  other  times  it  seemed  as  if  I  wasn't." 
In  answer  tO'  a  direct  question  about  her  feeling  of  confusion  she 
said  "I  don't  know.  I  know  I  have  lots  of  good  friends,  they 
all  want  to  help  me  and  it  seems  as  if  everything  got  mixed  up 
between  the  L.'s  (her  married  name)  and  the  G.'s  (her  maiden 
name).  This  was  apparently  an  elaboration  of  the  wavering 
ideas  she  had  about  her  singleness  or  her  married  state.  Once 
after  referring  to  her  husband  as  her  sweetheart  whom  she  was 
to  marry,  and  immediately  thinking  that  perhaps  he  had  married 
somebody  else,  she  added,  with  a  sigh,  "The  more  this  goes  on, 
the  more  mixup."  In  short,  any  question,  even  on  some  appar- 
ently neutral  topic,  seemed  to  start  up  conflicting  ideas  in  her 
mind,  the  inconsistency  of  which  she  recognized  without  being 
able  to  control  their  appearance.  Hence,  whenever  she  was 
spoken  to,  she  became  perplexed  and  distressed. 

Her  orientation  gradually  improved  so  that,  although  it  re- 
mained vague,  it  was  no  longer  glaringly  inaccurate.  Then  quite 
suddenly  she  one  day  came  to  a  nurse  and  asked  how  long  she  had 
been  in  the  hospital.  When  told,  she  remarked  that  it  seemed 
as  if  she  had  spent  the  whole  winter  there.  She  was  examined  at 
once  and  found  to  be  quite  clear  and  at  first  in  good  control  of 
her  faculties.  She  remembered  a  good  many  of  her  ideas,  in  fact 
was  able  to  elaborate  a  little  from  memory  on  what  had  already 
been  reported  from  her  utterances  during  the  psychosis.  The 
recovery  was  not  immediately  complete,  however,  for  at  this 
examination,  when  told  that  she  had  constantly  given  her  maiden 
name,  she  became  distressed  and  said  the  physician  was  trying 
to  mix  her  up  and  was  reluctant  for  this  reason  to  discuss  her 
ideas.     This  soon  passed,  however,  and  within  a  few  days  she 


SPECIAL  CASES  155 

was  quite  normal  and  had  remained  so  for  some  months  after  her 
discharge  from  the  hospital,  when  last  seen.  In  fact,  according 
to  the  husband,  she  was  in  better  mental  and  physical  health 
following  the  psychosis  than  she  had  been  for  years. 

Essentially,  then,  this  case  shows  what  was  at 
first  a  typical  partial  stupor,  but  soon  became  com- 
plicated by  a  tendency  for  questioning  to  provoke 
rather  a  free  flow  of  ideas  and  a  distressed  per- 
plexity. This  symptom  of  perplexity  soon  grew  to 
dominate  the  clinical  picture,  so  that  the  psychosis 
was  really  a  perplexity  ushered  in  by  a  brief  stupor 
reaction  with  a  background  of  stupor  symptoms 
running  through  it.  The  second  case  shows  similar 
tendencies  but  different  from  the  one  whose  history 
has  just  been  cited  in  that  the  perplexity  was  never 
complained  of  by  the  patient  herself  and  that  her 
emotional  reactions  were  more  marked  and  varied. 

Case  17. — Celia  C.  Age:  18.  Admitted  to  the  Psychiatric 
Institute  May  2,  1914. 

F.  H.  Four  years  after  this  attack  her  mother  was  a  patient 
in  the  hospital  with  an  atypical  manic-depressive  psychosis  from 
which  she  apparently  recovered. 

P.  H.  The  patient  herself  was  described  by  superficial  ob- 
servers as  being  bright,  sociable,  well-informed  and  very  ambitious. 

When  18  years  of  age  she  was  working  very  hard  preparing 
for  some  examinations,  and  worried  lest  she  should  fail  in  them. 
Some  years  later  the  patient  accounted  for  her  psychosis  by 
saying  she  had  a  quarrel  with  her  sister,  immediately  after  which 
she  began  to  feel  depressed.  The  anamnasis  states  that  she  was 
slow,  complained  of  not  being  able  to  think  and  feeling  as  if  she 
had  no  brain.  She  was  sent  to  a  general  hospital,  where  she  was 
apprehensive,  wanted  her  mother  to  stay  with  her  and  one  night 
called  out  "Mother," 


156  BENIGN  STUPORS 

The  case  being  recognized  after  a  few  days  as  a  psychosis, 
she  was  sent  to  the  Observation  Pavilion,  where  she  was  described 
as  jumping  about  in  bed  in  a  jerky,  purposeless  manner,  resistive 
when  anything  was  done  for  her,  and  mute.  Her  sister  reported 
that  when  she  visited  her  the  patient  said  "Go  away,  I  am  dead." 

On  admission  she  looked  dazed,  stared  vacantly  and  had  a 
tendency  to  draw  the  sheet  over  her.  When  put  on  her  feet  she 
let  herself  fall  limply.  At  times  she  became  agitated,  sobbed  and 
cried  loudly,  especially  when  attempts  were  made  to'  examine 
her  physically,  or,  when  she  was  asked  questions,  she  scarcely 
spoke. 

Her  psychosis  lasted  but  a  little  more  than  three  months  under 
observation  and  was  characterized  by  the  following  symptoms : 
She  was  usually  in  bed,  staring  blankly  or  appearing  otherwise 
quite  indifferent  and  apathetic,  but  not  infrequently,  especially 
during  the  first  few  weeks,  she  was  quite  restless,  resistive, 
whined  and  suddenly  appeared  startled  or  distressed  with  no 
occasion  for  this  reaction  in  the  environment.  Rarely  she  was 
suddenly  assaultive.  When  attem.pts  were  made  to  examine  her, 
she  was  frequently  mute  or  would  repeat  the  question  with  a 
rising  inflection,  not  getting  anywhere,  or  would  say,  "What  shall 
I  say,"  or  "I,  I "  never  finishing  her  sentence.  After  orienta- 
tion questions  she  might  say  "This  is — this  is — this  is "  all 

this,  together  with  a  rather  perplexed  appearance,  gave  the 
impression  of  considerable  bewilderment,  but  at  no  time  did  she 
complain  of  autopsychic  perplexity.  It  was  difficult  to  judge  of 
her  orientation  on  account  of  her  failure  to  answer  questions, 
but  it  soon  appeared  that  she  knew  the  names  of  the  nurses,  for 
she  sometimes  called  them  spontaneously  by  name.  She  always 
ate  reluctantly. 

During  these  examinations,  however,  other  symptoms  often  ap- 
peared. When  she  was  talked  to,  she  was  apt  to  indulge  in 
depressive  statements  and  show  considerable  distress.  Such 
remarks  were:  "I  must  confess  my  guilt,"  "I  am  a  bad  girl  and 
I  have  to  face  my  guilt,"  or  "I  have  sinned,"  or,  standing  up  with 
a  dramatic  air,  "I  must  stand  up  and  tell  the  truth."  Once  she 
said,  "It  is  too  late  to  live  now."  She  spoke  of  having  lied  and 
usually  would  not  say  what  about,  but  once  on  questioning  replied 
"I  said  I  would  not  tell  what  happened  here."     She  was  asked, 


SPECIAL  CASES  157 

What  do  you  mean?  and  answered  "I  took  my  oath  not  to  tell 
anything."  Pressed  further  she  said  that  the  nurses  poisoned 
her.  Another  time  she  said  she  was  in  prison.  To  her  aunt  who 
visited  her  she  said,  "I  am  a  prostitute/'  and  once  she  remarked 
to  the  doctor,  "I  have  killed  my  honor,"  and  on  another  occasion 
in  the  middle  of  the  night  she  called  out,  "Chinatown  Charlie, 
come  here."     She  thought  the  doctor  was  her  brother. 

Most  of  these  statements  were  associated  with  painful  emotion, 
but  there  were  a  few  occasions  when  an  element  of  elation 
cropped  out.  Thus  on  one  occasion  she  laughed,  another  time 
gripped  the  doctor's  pad  and  tried  to  read  it.  When  the  nurse 
laughed,  she  made  a  funny  grimace  at  her  and  said  "Why  do  you 
laugh?"  Again  she  once  sang  two  songs,  but  after  the  first  verse 
got  stuck  and  kept  repeating  one  word. 

At  the  end  of  three  months  she  improved  rather  rapidly  and 
was  in  a  condition  for  discharge  as  "recovered"  a  month  later. 
Retrospectively  she  said  that  she  recalled  feeling  guilty,  thinking 
that  her  mother  was  dead,  having  been  killed  by  the  patient  as  a 
result  of  worrying  over  the  latter's  failure  in  her  examinations 
and  refusal  to  eat.  She  remembered,  too,  that  at  times  she 
thought  the  building  was  burning.  Some  things  like  "Chinatown 
Charlie"  she  denied  remembering,  although  she  had  a  good  recol- 
lection for  the  external  facts  throughout  the  psychosis.  ,  Her 
insight  was  superficially  good,  but  she  was  reluctant  to  discuss  her 
psychosis,  in  fact  claimed  that  she  had  been  made  more  of  a 
lunatic  by  coming  to  the  hospital  than  she  was  on  admission. 

Some  five  years  later  she  had  another  somewhat  similar  attack, 
again  following  a  quarrel,  this  time  with  a  fellow  employee.  In 
this  second  psychosis,  however,  manic  elements  were  much  more 
prominent. 

Here  again,  then,  we  have  the  symptoms  of  appar- 
ent apathy,  inactivity,  and  similar  ideas  of  death, 
but  the  thinking  disorder  was  possibly  not  very 
profound,  inasmuch  as  she  had  a  good  memory  for 
external  events.  Her  ideas,  too,  are  much  more 
florid  than  those  which  we  customarily  meet  with  in 
stupor  cases,  but  the  most  marked  peculiarity  was 


158  BENIGN  STUPORS 

that  this  ''stupor''  was  liable  to  constant  interrup- 
tion, either  spontaneously  or  as  a  result  of  question- 
ing, which  always  produced  a  mood  reaction.  She 
was  apathetic  only  so  long  as  she  was  left  alone.  In 
other  words,  whenever  an  effort  was  made  to  test 
what  seemed  to  be  apathy,  the  evidences  of  it  dis- 
appeared. 

The  third  case  to  be  considered  is  somewhat  like 
that  of  the  first,  Anna  L.  (Case  16),  in  that  with 
the  inactivity  and  apathy  there  was  a  coincident 
subjective  perplexity.  The  apathy,  however,  was 
less  marked  than  in  the  case  of  Annie  L. 

Case  18. — Catherine  M.  Age :  24.  Admitted  to  the  Psychiatric 
Institute  November  10,  1913. 

F.  H.  Information  as  to  the  family  is  confined  to  the  two 
parents.  The  mother,  who  was  frequently  seen,  seemed  to  be  a 
natural,  sensible  woman.  The  father,  on  the  other  hand,  had 
been  alcoholic  all  his  life,  had  had  two  convulsions  while  drinking, 
and  had  little  respect  from  any  member  of  the  family,  including 
the  patient. 

P.  H.  The  patient  was  said  always  to  have  been  healthy,  from 
a  physical  standpoint,  although  never  robust.  She  got  on  well 
at  school,  and  then  worked  first  as  a  stock  girl  and  later  as  clerk 
in  a  department  store,  where  her  work  was  efficient  and  she 
advanced  steadily.  As  a  child  she  played  freely  with  other 
■  girls  but  little  with  boys.  As  she  grew  older  she  moved  about 
socially  a  little  more,  made  the  acquaintance  of  men  as  well  as 
of  girls,  but  never  cared  much  for  the  former  and  had  no  love 
affairs  until  she  met  her  husband.  She  was  never  demonstrative 
but  alwaj'-s  rather  quiet  and  modest.  Occasionally  she  spoke  of 
thinking  that  people  talked  about  her,  but  the  informant  doubted 
if  she  brooded  over  this,  because  she  was  not  of  a  worrying 
disposition.  Considering  the  ideas  which  appeared  in  her 
psychosis,  it  is  striking  that  in  her  normal  life  she  was  rather 


SPECIAL  CASES  159 

antagonistic  towards  her  father  on  account  of  his  alcoholism  and 
the  crudity  of  his  speech  and  manners. 

When  she  met  her  husband  she  liked  him  from  the  first, 
although  she  at  no  time  became  really  demonstrative.  They  were 
engaged  for  a  year,  during  which  time  she  agreed  to  a  postpone- 
ment of  three  months  for  the  marriage,  which  was  suggested  by 
her  mother.  For  some  time  before  this  event  she  was  working 
harder  than  usual  and  seemed  a  bit  worn  out.  She  ceased  working 
a  month  before  marriage  and  improved  physically,  although  she 
became  rather  nervous,  that  is,  she  was  more  easily  startled,  an 
accentuation  of  what  had  been  a  characteristic  for  some  years. 
Her  husband  stated  that  at  this  time  she  became  fearful  of  the 
approaching  marriage  relations  and  asked  him  to  be  kind  to  her 
in  this  respect.  She  was  married  a  year  before  admission.  For 
two  and  a  half  months  she  refused  intercourse  and  visited  her 
mother's  home  a  great  deal.  She  finally  submitted.  She  was 
quite  frigid  but  became  pregnant  at  once.  Her  abnormality  then 
became  apparent.  She  kept  the  fact  of  her  pregnancy  to  herself 
for  several  months  and  then  when  she  told  her  mother  wanted 
to  have  an  abortion  performed.  Neurotic  symptoms  appeared. 
She  became  sensitive  with  her  husband,  correcting  his  grammar 
and  cried  easily.  She  also  began  to  be  anxious  about  the  ap- 
proaching childbirth,  and  with  this  became  more  religious. 

For  the  first  few  days  after  the  delivery,  she  was  fussy  with 
the  nurse  so  that  two  in  succession  had  to  be  discharged.  On 
the  fifth  day  she  woke  up  and  seeing  a  nurse  lying  on  the  couch 
beside  her  bed  thought  the  latter  was  colored.  On  the  seventh 
day  she  had  a  dream  in  which  she  thought  she  "nearly  died  in 
childbirth."  Then  she  began  to  talk  of  dying  for  her  baby  or 
of  having  two  babies,  of  dying  herself  and  rising  again  after 
Easter  Sunday.  She  became  antagonistic  to  her  husband  and 
with  this  excited  and  confused  so  that  she  was  taken  to  the 
Observation  Pavilion. 

On  admission  she  looked  pale  and  exhausted,  had  a  slight  tem- 
porary fever  and  a  coated  tongue.  Her  orientation  was  usually 
vague  but  sometimes  she  gave  fair  answers.  Her  verbal  produc- 
tions were  rather  fragmentary  and  with  the  exception  of  some 
repetitions  there  did  not  seem  to  be  any  special  topics  which 
dominated  her  train  of  thought. 


160  BENIGN  STUPORS 

For  some  days  the  great  weakness  and  the  slight  fever  con- 
tinued, and  then,  as  it  gradually  cleared  up,  there  came  a  change 
in  her  mental  condition  that  settled  into  the  state  which  charac- 
terized the  rest  of  her  psychosis.  She  talked  less  and  was  often 
quite  inactive,  frequently  lying  with  her  eyes  closed  for  long 
periods,  or  sat  or  stood  about.  Such  movements  as  she  made 
were  slow  and  languid.  Her  expression  was  either  blank,  ab- 
sorbed, or  gave  the  appearance  of  peculiar  appealing  perplexity. 
This  last  was  not  infrequently  associated  with  a  rather  sheepish 
smile.  She  was  never  resistive  and  always  ate  and  slept  well. 
With  the  exception  of  a  few  times  she  did  not  soil  herself.  The 
most  interesting  feature  of  her  mood  reaction  was  that  in  a 
general  setting  of  a  slight  perplexity  there  appeared  at  times 
and  evidently  associated  with  definite  ideas,  changes  in  her  emo- 
tional state.  Sometimes  this  was  a  matter  of  distress  or  of  mild 
ecstasy,  sometimes  she  became  markedly  blocked.  There  was  at 
no  time  any  frank  elation,  but  often  an  appropriate  smile,  that 
is,  appropriate  to  the  situation  and  to  the  thought  to  which  she 
was  giving  expression  at  the  time.  Then,  rarely,  there  were 
sudden  bursts  of  peculiar  conduct,  such  as  throwing  herself  on 
the  floor  or  running  down  the  hall.  When  questioned  as  to  her 
motive  for  these  acts,  she  would  flush,  look  perplexed  and  ap- 
parently be  unable  to  explain  them. 

Her  verbal  productions  dealt  with  a  rather  limited  range  of 
topics  which  can  be  briefly  summarized.  As  in  the  other  cases, 
the  reader  will  notice  that  the  bulk  of  these  ideas  are  of  a  kind 
not  usually  prominent  in  the  typical  stupor  cases.  Many  of  her 
thoughts  seemed  centered  around  her  husband.  She  always  knew 
him  when  he  visited  her,  but  in  her  thoughts  there  was  a  constant 
change  as  to  his  personality.  She  persistently  confused  him 
with  the  physicians,  with  her  father,  and  with  God,  and  one 
remark  is  typical,  "I  thought  he  was  God,  priest,  doctor,  lawyer — 
well,  I  wanted  to  go  to  Heaven;  I  thought  he  would  still  be  my 
husband ;  I  always  hoped  that  I  would  be  home  in  Heaven."  Not 
unnaturally  with  this  confusion  there  were  doubts  about  her 
marriage.  People  said  her  marriage  was  wrong  and  her  husband 
bad.  Frequently  she  thought  he  was  dead,  or  voices  informed 
her  that  she  was  not  married  to  him,  or  that  he  was  the  devil  in 
Hell.     In  this  connection  she  also  said  that  people  called  her  a 


SPECIAL  CASES  161 

whore,  or  it  seemed  as  if  she  were  accused  of  not  being  married. 

As  prominently  as  appeared  the  ideas  of  the  invalidity  or  im- 
possibility of  her  marriage,  to  the  same  extent  did  her  father 
assume  an  important  role  for  her.  As  a  rule  he  appeared  in 
religious  guise  as  God,  but  often  he  was  the  doctor — "I  knew  my 
father  at  home  and  my  father  in  Heaven ;  which  God  do  you 
mean?  did  you  say  God  or  father"?"  At  times  she  spoke  of 
being  in  Heaven  and  that  God  seemed  to  be  God,  doctor  or  priest. 
In  this  connection  there  were  ideas  of  being  under  the  power  of 
some  one,  God,  devil  or  father. 

As  is  usually  the  case  where  strong  interest  is  expressed  in 
the  father,  ideas  of  the  mother  being  dead  occurred,  although 
in  the  frankest  form  she  reported  them  as  dreams;  for  instance, 
one  night  she  woke  up  screaming,  said  that  she  had  dreamed  that 
her  mother  was  dead  and  her  sister  dying.  That,  in  the 
psychoanalytic  sense,  this  represented  a  removal  of  a  rival, 
making  union  with  her  father  easy,  appeared  the  statement 
that  her  father  was  dead  but  that  she  had  dreamed  he  had 
come  to  life  again  for  some  one  else.  When  asked  what  she 
meant,  the  question  had  to  be  repeated  several  times,  then  she 
said  "My  mother  died,  my  father  and  mother  had  a  quarrel." 
There  is  more  than  a  suggestion  here  of  a  difference  in  the 
significance  of  death,  in  so  far  as  it  concerned  the  two  parents. 
The  mother  dies  and  remains  dead,  that  is,  she  is  gotten  rid  of. 
The  father  dies  but  takes  on  a  spiritual  existence  and  comes  to 
life  again,  a  frequent  method  in  psychoses  for  legitimizing  the 
idea  of  union  with  the  parent  by  elimination  of  the  grossly 
physical. 

There  were  strikingly  few  allusions  to  the  plainly  sexual.  She 
spoke  of  being  married  to  the  doctor,  and  even  went  so  far  as 
to  say  that  they  belonged  together  in  bed.  On  another  occasion 
she  called  him  "darling."  Once  she  reported  that  it  was  said 
that  she  was  going  to  have  babies  and  babies  and  babies.  These 
references  were,  however,  quite  isolated,  so  that  the  erotic  formed 
a  very  small  part  of  her  productions. 

Delusions  of  death,  we  have  seen,  are  the  most  constant  content 
of  true  stupors.  In  this  case  they  were  present  but  distinctly 
in  the  background.  She  spoke  quite  frequently  of  being  in 
Heaven.     She  also  talked  of  being  crucified.     Once  she  said  "I 


162  BENIGN  STUPORS 

died  but  I  came  back  again."  This  last  utterance  was  rather 
significant  in  that  frankly  accepted  ideas  of  death  were  unusual; 
for  instance,  she  would  say  sometimes,  "I  think  I  am  in  Heaven, 
again  not.    It  confuses  me,  but  I  know  I  am  in  Heaven." 

In  general,  then,  her  ideas  were^  on  the  whole,  not  at  all  typical 
of  stupor  but  much  more  like  those  met  with  in  other  manic- 
depressive  conditions.  Correlated  with  this  was  an  unusual  mood 
picture.  Quietness  and  apparent  apathy  of  the  patient  were 
interrupted  by  little  bursts  of  emotion,  and  throughout  the 
psychosis  there  was  a  coloring  of  perplexity.  Not  only  was  this 
last  objectively  noticeable,  but  she  spoke  very  frequently  of  it 
and  always  in  connection  with  the  inconsistency  of  the  ideas  in 
her  mind  which  puzzled  her.  For  instance,  in  speaking  to  the 
doctor  she  said  "I  think  of  you  as  Bill  (her  husband's  name) 
sometimes — I  get  confused  thinking  of  Bill  as  God,  doctor,  lawyer, 
priest."  Again,  referring  to  her  husband,  she  made  these  curio'us 
statements :  "They  seemed  to  speak  of  him  as  being  in  the 
wrong — the  right — ^it  seems  that  the  right  devil  is  the  wrong  one 
for  me — they  say  he  is  not  the  right  one  for  me;  they  say  he 
went  wrong  from  the  time  we  were  married."  Again,  she  said 
that  she  did  not  know  who  her  father  was,  and  went  on:  "It 
puzzles  me,  this  father  business,  I  knew  my  father  at  home  and 
my  father  in  Heaven."  Again,  "Which  God  do  you  mean?  Did 
you  say  God  or  father?"  A  hint  as  to  how  this  subjective 
confusion  made  the  environment  seem  uncertain  comes  from  the 
statement,  "You  looked  like  the  devil  and  yet  you  were  God." 

Distress  and  anxiety  appeared  not  infrequently  and  always 
appropriately.  The  distress  was  usually  occasioned  by  an  idea 
of  injury  to  others,  as  when  she  cried  over  the  fancied  accusation 
of  drowning  her  husband  and  mother;  or  in  connection  with 
accusations  of  herself,  such  as  when  she  reported  "They  called 
me  a  whore."  As  has  been  stated,  there  was  never  any  frank 
elation,  but  an  element  of  pleasurable  expansive  emotion  was 
frequently  present  in  connection  with  her  religious  utterances. 
This  came  particularly  when  she  spoke  of  union  with  her  father 
as  God.  She  seemed  to  swell  with  ecstatic  emotion.  It  was 
especially  well  marked  once  when  she  threw  herself  on  the  floor 
and  when  asked  what  she  was  trying  to  do  replied,  "I  want  to 
do  what  God  wants  me  to  do,  drop  dead  or  anything  at  all." 


SPECIAL  CASES  163 

Perhaps  the  most  unusual  affective  reaction  was  a  blocking  which 
occurred  when  certain  topics  appeared.  This  is  a  phenomenon 
quite  unusual  for  stupor,  where  speech  seems  to  stimulate  and 
arouse  the  patient  as  a  rule.  One  got  the  impression  that  ideas 
tended  to  come  into  this  patient's  mind  which  were  painful 
enough  to  disturb  her  capacity  for  connected  thought.  A  good 
example  of  this  reaction  was  when  she  was  speaking  of  her 
father  having  died  and  coming  to  life  again.  On  being  asked 
what  she  meant,  she  became  quite  blocked  and  the  question  had 
to  be  repeated  several  times,  when  finally  the  apparently  unre- 
lated statements  appeared :  "I  dreamed  my  mother  died — they 
had  a  quarrel."  Who  had  a  quarrel?  she  was  asked,  and  replied 
"My  mother  and  father."  Apparently  her  thinking  about  her 
father  coming  to  life  for  some  one  not  her  mother  stimulated 
deeply  unconscious  ideas  concerning  the  separation  of  her  mother 
and  father,  and  her  taking  the  mother's  place,  and  these  ideas 
were  sufficiently  revolutionary  to  upset  her  capacity  of  speech 
for  the  time  being. 

She  recovered  completely  about  six  and  a  half  months  after 
her  admission. 

If  we  consider  together  the  common  features  of 
these  three  cases,  we  see  that  they  resemble  stupors 
only  in  the  presence  of  inactivity  and  apparent 
apathy.  It  is  trne  that  death  appears  in  the  idea- 
tional content  but  not  with  that  prominence,  border- 
ing on  exclusiveness,  which  characterizes  such  delu- 
sions in  the  true  stupors.  These  three  patients  give 
one  the  impression  of  being  absorbed  in  thoughts 
that  have  many  variations.  It  seems  as  if  they  had 
difficulty  in  grasping  the  facts  of  the  environment, 
while  feeling  at  the  same  time  the  vividness  of  the 
changing  internal  thoughts,  hence  a  confusion  de- 
velops which  is  either  subjective,  objective,  or  both. 


164  BENIGN  STUPORS 

It  is  probably  the  introversion  of  attention  which 
gives  rise  to  the  apparent  apathy,  becanse  normal 
emotions  emerge  as  part  of  our  contact  with  reality 
around  us.  This  lack  of  contact  with  the  environ- 
ment leads  also  to  inactivity.  If  one's  attention  and 
interest  is  turned  inwards,  there  can  be  no  evidence 
of  mental  energy  exhibited  until  the  patient  is 
roused  to  contact  with  the  people  or  things  about 
him.  It  is  noteworthy  that  in  these  cases  emotional 
expression  emerged  when  the  patients  were  stimu- 
lated to  some  productiveness  in  speech. 

These  conditions  really  constitute  a  different 
psychosis  in  the  manic-depressive  group,  essentially 
they  are  perplexity  states  such  as  have  recently  been 
described  by  Hoch  and  Kirby.^  Not  infrequently 
we  see  exhibitions  of  this  tendency  in  what  are 
otherwise  typical  stupors.  For  example,  Mary  F. 
(Case  3)  (the  third  case  to  be  described  in  the  first 
chapter),  showed  for  a  few  days  after  admission  a 
condition  when  she  was  essentially  somewhat  rest- 
less in  a  deliberate  aimless  way.  At  the  same  time 
she  looked  dazed  or  dreamy.  With  this  restlessness 
she  appeared  at  times  '^a  little  apprehensive. ' '  Al- 
though she  spoke  slowly,  with  initial  difficulty  she 
answered  quite  a  number  of  questions.  Her  larval 
perplexity  was  evidenced  by  the  doubt  expressed  in 
a  good  many  of  her  utterances,  such  as,  ^'Have  I 

^  Hoch,  August,  and  Kirby,  George  H. :  '  ^  A  Clinical  Study  of 
Psychoses  Characterized  by  Distressed  Perplexity.  ArcMves  of 
Neurology  and  Psychiatry,  April,  1919,  Vol.  I,  pp.  415-458. 


SPECIAL  CASES  165 

done  something!''  ''Do  people  want  something!" 
''I  have  done  damage  to  the  city,  didn't  I!"  When 
asked  what  she  had  done,  she  said,  ''I  don't  know." 
She  asked  the  physician,  ''Are  you  my  brother!" 
and  when  questioned  for  her  orientation  said,  "Is 
not  this  a  hospital!"  The  atmosphere  of  perplexity 
also  colored  the  information  which  she  did  recall 
correctly;  for  instance,  when  asked  her  address,  she 

said,    "Didn't   I   live   at   !"    then   giving   the 

address  correctly. 

As  stated  in  Chapter  V  dealing  with  the  ideational 
content  of  stupor,  one  has  to  look  on  the  delusions 
of  patients  as  symptoms  subject  to  analysis  and 
classification  just  as  truly  as  the  variations  in  mood 
or  intellectual  processes,  in  fact  they  should  be 
subject  to  the  same  correlation  as  are  the  mental 
anomalies  which  are  usually  studied,  particularly  if 
we  are  to  understand  these  psychoses  as  a  whole. 
Let  us,  therefore,  consider  the  death  ideas  in  the 
three  cases  studied  in  this  chapter.  We  find  that,  as 
in  the  ordinary  stupors,  there  are  delusions  of 
death,  also  of  mutual  death  (with  the  father),  but 
there  is  a  tendency  to  elaboration  so  that  the  death 
is  only  part  of  a  larger  CEdipus  drama,  the  rest  of 
which  is  usually  lacking  in  stupors.  Here  it  is  pres- 
ent. So  we  have  thoughts  of  the  death  of  the  mother 
or  husband,  another  rival,  considerable  preoccupa- 
tion with  Heaven,  and  also  erotic  fancies. 

We  find  in  manic-depressive  insanity  a  tendency 
for  more  or  less  specific  ideational  contents  with  dif- 


166  BENIGN  STUPORS 

ferent  types  of  the  psychoses.^  For  example,  tliere 
are  religious  and  erotic  fancies  or  ambitious  schemes 
dominating  the  thoughts  of  manic  patients,  fears  of 
aggression  and  injury  met  with  in  anxiety  cases,  and 
so  on.  In  stupors,  death  seems  to  be  a  state  of 
non-existence  with  other  meanings  lacking  or  only 
hinted  at  occasionally.  When  it  tends  to  be  elabo- 
rated, it  leads  over  to  formulations  suggesting  per- 
sonal attachments  and  emotional  outlet,  and  then 
we  are  apt  to  find  interruptions  of  the  pure  stupor 
picture.  For  example,  Charlotte  W.  (Case  12), 
whose  case  has  been  described,  thought  much  about 
being  in  Heaven  and  ended  with  a  hypomanic  state. 
Atypical  symptoms  appear  just  as  constantly  in 
these  cases,  as  do  the  atypical  ideas.  In  other 
words,  the  thought  content  is  definitely  correlated 
with  the  clinical  picture. 

As  the  clinical  pictures  show  the  relationship  of 
stupor  to  other  psychoses,  so  there  is  also  a  correla- 
tion with  varying  formulations  of  the  death  fancy. 
We  are  now  in  a  position  to  define  more  narrowly 
what  death  means  in  stupor.  It  is  an  accepted  fact, 
a  Nirvana  state.  When  death  means  union  with  God 
or  appears  in  other  religious  guise,  manic  symptoms 
tend  to  develop.  When  it  is  unwelcome  and  appears 
as  *' being  killed,"  we  find  anxiety  symptoms.  A 
patient  can  conceive  of  death  variously  and  have 

^  Hoch,  August :  ' '  A  Study  of  the  Benign  Psychoses. ' '  Johns 
HopUns  Hospital  Bulletin,  May,  1915,  XXVI,  165. 

A  book  on  ''the  psychology  of  manic-depressive  insanity"  will 
shortly  appear  by  the  editor. 


SPECIAL  CASES  167 

various  clinical  pictures.  A  knowledge  of  the  meta- 
morphoses of  ideas  and  their  relationship  to  other 
symptoms  enables  us  to  understand  such  cases,  that, 
without  this  key,  seem  confused  and  lawless  jumbles 
of  symptoms.  Such  theories  tend  to  justify  the  view 
of  essential  unity  of  the  manic-depressive  group. 

It  would  be  instructive  at  this  point  to  consider 
another  case  which  illustrates  beautifully  how  a 
stupor  reaction  may  crystallize  out  of  other  manic- 
depressive  states  when  attention  has  become  fo- 
cused on  personal  death.  This  patient  went 
through  four  phases  while  under  observation.  First, 
while  showing  a  perplexed  expression  but  with  fair 
orientation,  she  gave  utterance  to  erotic  and  expan- 
sive fancies.  She  was  restless,  somewhat  intractable 
and  gave  the  impression  of  brooding  over  her  imagi- 
nations rather  than  luxuriating  in  them.  In  other 
words,  her  condition  seemed  to  be  more  that  of  ab- 
sorbed than  active  mania.  Second,  these  same  ideas, 
somewhat  reduced,  continued  in  an  apathetic  state 
while  impulsive  symptoms  developed:  She  began 
to  shout  like  a  huckster  to  be  taken  to  Heaven  and 
made  numerous  atfectless,  suicidal  attempts.  Third, 
came  a  true  stupor  and,  fourth,  a  period  of  recovery 
when  the  stupor  S3rmptoms  all  disappeared  but  in- 
sight into  the  falsity  of  her  ideas  was  lacking. 

Case  19.— Celia  H.  Age:  19.  Admitted  to  the  Psychiatric 
Institute  October  22,  1913. 

F.  H.  The  father  was  livino:;  he  always  drank,  and  especially 
in   later  years  contributed  little  to  the  support   of  the  family. 


168  BENIGN  STUPORS 

The  mother  was  living  and  said  to  be  normal,  while  a  brother 
was  coineidentally  insane,  with  a  recoverable  psychosis. 

P.  H.  The  mother  stated  that  the  patient  was  bright  at  school, 
enjoyed  company  and  going  out,  had  a  droll  wit,  was  not  at  all 
seclusive,  no  dreamer,  helped  to  support  the  family  and  was 
efficient.  She  was  very  much  attached  to  her  brother  and  once 
said  that  if  anything  should  ever  happen  to  him  she  thought  she 
would  die.  She  also  cared  much  for  her  older  sister,  with  whom 
she  worked,  and  for  her  mother. 

Three  months  before  the  patient's  admission  her  brother  became 
depressed,  mute,  seemed  worried,  cried  at  times.  He  was  sent 
to  the  country.  Two  months  before  admission,  when  the  mother 
and  the  patient  went  to  bring  the  brother  to  town,  and  while 
they  were  at  the  station,  he  suddenly  tried  to  throw  himself  under 
a  train  but  was  restrained  just  in  time.  The  patient  appeared 
intensely  frightened,  but  did  not  talk.  In  fact,  she  seemed  some- 
what bewildered  and  at  once  became  dull.  "Her  movement  and 
manner  were  much  as  at  present." 

When  the  patient  was  able  later  to  give  a  retrospective  account 
of  the  onset,  she  claimed  that  for  some  months  before  this 
incident  she  saw  that  her  brother  was  losing  his  mind.  She 
worried  about  this  as  well  as  about  her  work,  and  felt  worn  out. 
She  said  that  when  the  brother  tried  to  throw  himself  under  the 
train  she  was  terrified  and  could  not  speak  or  move,  and  that  her 
mind  got  upset  at  once,  "I  lost  my  memory."  The  others  forgot 
her  and  left  her  alone  on  the  platform.  Strangers  put  her  on 
another  train  and  she  knew  nothing  until  she  arrived  at  home. 

The  mother  added  that  at  the  time  when  the  incident  with  the 
brother  happened,  the  patient  was  menstruating  and  that  this 
ceased  at  once. 

At  home  she  sat  about  inactive  and  did  not  seem  even  to  worry. 
Whenever  any  one  asked  her  about  her  brother  she  replied  that 
he  was  dead.  For  two  weeks  before  admission  she  said  she  was 
rich,  that  she  owned  all  the  property  around.  She  also  said  she 
was  married  to  Mattie  S.  In  this  connection  the  mother  says 
that  a  foolish  neighborwoman,  the  mother  of  Mattie  S.,  told  the 
patient  since  her  sickness,  by  way  of  encouragement,  that  she 
should  marry  her  son  (the  man  mentioned).    Finally,  the  patient 


SPECIAL  CASES  169 

also  expressed  the  idea  that  her  mother  was  a  stranger,  that  her 
real  mother  was  dead. 

At  the  Observation  Pavilion  she  was  described  as  wandering 
about  in  a  perplexed  manner,  restless,  resistive,  answering  few 
questions  and  in  a  low  tone.  She  said  things  were  "changed," 
also  that  she  was  married  to  S. 

Under  Observation:  1.  For  about  ten  days  the  patient's  con- 
dition may  be  described  as  follows:  The  most  striking  feature 
was  a  certain  restlessness  with  insistence  on  going  out,  with 
complaints  that  this  and  that  had  been  done  to  her  and  with 
senseless  struggling  when  interfered  with.  But  all  the  motions 
were  slow,  the  whole  restlessness  aimless  and  impulsive.  Although 
the  facial  expression  was  somewhat  perplexed,  it  changed  re- 
markably little,  and  whenever  asked  whether  she  felt  worried  or 
anxious  she  denied  it,  and,  indeed,  there  was  only  a  suggestion 
of  perplexity  in  her  face. 

The  ideas  which  she  expressed  during  this  time  referred  to 
a  few  topics  only,  namely,  marriage,  wealth,  and  State  prison. 
The  remarkable  fact  was  that  all  the  ideas  about  marriage  and 
wealth  were  spoken  of,  often  immediately,  again  after  some 
interval,  now  in  the  positive  and  again  in  the  negative  sense. 
Thus  she  said  she  was  "Mrs.  S.,"  again  "You  kept  me  from 
.marrying  Mattie  S.,"  or  "I  am  not  supposed  to  be  here — I  am 
a  married  person,"  but  also  "You  kept  me  from  getting  married." 
Or,  "Take  off  that  black  dress,  I  am  a  bride,"  again  "You  have 
taken  my  bridal  crown  off  my  head,"  "The  steamboats  (seen 
from  the  window)  are  mine — I  own  the  ships,  the  oceans,  the  land 
and  everything,"  or  again,  she  said  she  owned  a  kingdom,  was 
Sh.'s  wife,  a  wealthy  woman,  had  millions.  Sometimes  she 
connected  the  millions  with  Sh.  "Sh.  has  millions."  On  the 
other  hand,  she  said :  "I  owned  all  this  before  I  came.  I  have 
nothing  now,"  or  "You  have  taken  the  regal  crown  from  me," 
"You  have  made  a  pauper  of  me,"  "They  did  it  again,  they  took 
my  millions  away,"  or  "Let  me  out,  they  are  taking  my  millions." 

Other  ideas  throughout  this  period  were  that  this  was  a  State 
prison,  that  "bums"  were  around.  On  one  occasion  she  said 
"You  can't  put  down  all  these  things  and  make  me  out  a  lunatic." 
At  another  time  she  pulled  a  patient's  hair  and  then  said  without 
fun:     "I  fixed  the  leading  lady  of  the  dump — she  knows  a  lot, 


170  BENIGN  STUPORS 

but  she  does  not  know  enough  to  keep  her  soup  cool."  When 
questioned  about  this  woman  (who  at  the  time  while  cleaning  had 
moved  the  furniture),  she  said:     "I  don't  know  where  I  am  at." 

The  orientation  during  these  days  was  not  markedly  disordered, 
when  one  got  down  to  it.  Although  she  spoke  of  State  prison,  it 
was  always  found  she  knew  the  name  and  the  location  of  the 
hospital,  the  names  of  people  around  her,  even  the  date  approxi- 
mately, though  she  was  apt  to  say  it  was  February  19,  1492,  or 
October  19,  1492,  or  when  the  year  was  not  given  as  1492  she 
said  it  was  "1900  or  1901,  or  1911  or  1912."  Frequently,  how- 
ever, it  was  hard  to  hold  her  attention. 

Finally,  it  should  be  mentioned  that  she  very  often  wet  herself 
in  bed  or  when  standing,  even  when  standing  in  the  examining 
room. 

2.  The  period  following  and  lasting  for  two  months  may  be 
given  in  the  form  of  abstracts  of  each  note. 

November  7 :  Yesterday  quiet,  though  struggling.  Says  with- 
out change  of  expression,  "I  saw  four  people  killed — my  mother, 
my  brother,  a  priest,  and  my  dear  sister — ^we  were  all  killed." 
Again,  "I  don't  know  where  I  am,"  "I  am  an  orphan,  my  people 
died"   (without  affect). 

November  20:  More  quiet  recently,  says  little,  but  tries  to  get 
out  when  brought  to  the  examining  room,  but  when  not  prevented 
walks  slowly  about  as  before,  says  she  wants  to  go  home.  Looks 
peculiarly  blank. 

November  23:  Has  remained  quiet,  says  she  is  Dr.  M.'s  wife. 
But  when  told  she  is  not  married,  she  agrees.  Her  attitude  to- 
wards the  doctor  is  not  changed,  but  when  the  nurses  talk  to  him, 
she  has  tried  to  prevent  it. 

December  6:  Has  remained  quietly  in  bed,  gazing  about. 
Slow  in  motion.  She  has  spoken  of  being  Dr.  M.'s  wife,  again 
President  Wilson's  wife,  again  "Vincent  (brother)  is  the  ruler 
of  the  world." 

At  interview  says  little,  seems  abstracted,  answers  briefly  in 
low  tone.  (Does  anything  bother  you?)  "No."  (Are  you  nat- 
ural?) "Yes."  (Who  are  you?)  "C.  H."  (correct).  (You 
said  you  were  the  President's  wife?)  "No."  (Are  you  married?) 
"No."  (You  talked  about  the  kingdom?)  "I  own  the  kingdom" 
(affectlessly).     (Where  is  Vincent?)     "Here."     (Have  you  heard 


SPECIAL  CASES  171 

him?)  "Yes."  (What  did  he  say?)  "Nothing."  (Is  he  all 
right?)  "Yes."  (Where  is  your  mother?)  "Home."  (Why 
don't  you  go  home?)  "I  can't."  (Why  not?)  "I  can't."  (Why 
not?)  "The  family  tree  is  broken,  the  Cardinal."  (What  about 
him?)  "Nothing.  (Retrospectively  she  said  later  she  thought 
her  brother  was  a  cardinal.) 

December  8:  When  her  mother  visited  her  she  said  "It  is 
about  time  you  come — I  thought  you  were  dead."  Has  walked 
down  the  hall  "looking"  for  her  dead  cousin.  When  asked  if  she 
wanted  to  see  her  brother,  said,  "Ain't  he  dead?" 

December  12:  Cries  out  in  an  affectless  tone  like  a  huckster, 
"Father  MacN.,  take  me  to  Heaven,"  repeating  this  over  and  over. 

December  15:  Quiet  as  a  rule,  then  for  a  time  at  the  door, 
pulling  at  it  and  with  whining  voice  but  affectlessly  saying  "Give 
me  the  key — I  want  to  go  to  the  river — you  can't  keep  me  from 
Heaven — it  is  either  Heaven  or  the  river,  give  me  the  keys,  give 
me  the  keys,  open  the  door,"  "The  niggers  are  taking  possession." 
To  the  physician  tO'  whom  she  had  claimed  to  be  married,  often 
repeats  "You  don't  belong  to  me,  I  don't  belong  to  you."  (What 
about  the  niggers?)  "A  band  of  niggers,  that  is  all  they  are." 
(Are  the  nurses  niggers?)  "That  is  all  they  are."  Asked  about 
her  people,  she  says  "They  are  in  Heaven."  (Where  are  you?) 
"I  am  in  Heaven"  (without  change  of  expression).  Again,  when 
asked  where  her  people  are,  says  "At  home."  Then  she  went 
willingly  back  to  bed  and  was  quiet.  In  the  afternoon  she  again 
went  to  the  door  and  tried  to  get  out.  When  questioned,  she 
said  "I  don't  want  to  be  an  animal,"  "Everybody  is  making  an 
animal  of  me"  (pointing  to  an  animal  picture).  Then  again, 
while  trying  the  door,  repeats  in  the  same  affectless  manner  that 
she  wants  to  go  to  the  river,"  "to  the  bottom  of  the  river,"  "to 
Heaven  to  see  my  mother."  This  last  was  said  in  a  whining 
tone,  with  some  tears.  She  kept  turning  the  knob,  tried  to  get 
the  keys,  and  struggled  impulsively  when  prevented. 

December  23 :  Though  quiet  on  the  whole,  when  a  visitor  came 
yesterday,  she  ran  after  this  woman  saying  "I  want  my  genera- 
tions," and  clung  to  her,  and  to-day  at  intervals  keeps  talking 
about  wanting  to  see  her  generations  but  is  often  quiet.  (Retro- 
spectively she  said  she  wanted  to  see  all  her  ancestors  from  the 
beginning  of  time.) 


172  BENIGN  STUPORS 

December  27 :  Of  late  often  talks  affeetlessly  about  wanting 
to  die  or  wanting  to  go  to  Heaven,  struggling  impulsively  to  get 
medicine  away  from  the  nurses,  asking  for  poison,  trying  to  drink 
her  own  urine,  or  even  the  fluid  in  the  bed  pan  after  she  had  been 
given  an  enema,  all  evidently  with  suicidal  intent. 

December  28:  Still  constant,  impulsive  and  apparently  affect- 
less  attempts  at  suicide,  tries  to  get  medicine  away  from  nurses, 
to  get  the  fire  extinguisher  bottles,  a  bottle  of  ink,  etc.,  struggling 
when  prevented. 

But  when  examined  quiet,  even  smiles  at  a  joke.  When  ques- 
tioned, denies  feeling  either  worried  or  depressed.  She  said  she 
wanted  to  go  home.  She  gave  poor  attention  to  the  questions. 
Later  she  threw  a  wet  sheet  over  a  patient  and  laughed  (this  is 
rare).  Later  she  slapped  another  patient.  Again  she  began  to 
talk  about  wishing  to  go  to  the  grave.    Calls  Dr.  M.  "Uncle  John." 

December  30:  Talks  either  about  wanting  to  die,  or  wanting 
to  go  to  Heaven,  or  wanting  to  go  to  Ireland,  all  this  as  usual 
in  an  affectless  way.  Calls  Dr.  M.  "Uncle  John."  Keeps  shouting 
"Take  me  to  Ireland." 

January  9,  1914:  Often  quiet  in  bed,  again  goes  to  door, 
talks  about  wanting  to  go  "to  Heaven"  or  "to  Ireland."  On  the 
whole,  says  little. 

It  seems,  then,  that  the  transition  was  not  abrupt,  that  many 
traits  of  the  first  period  remained,  but  that  she  was  on  the  whole 
much  quieter,  with  the  exception  of  some  spells  when  she  insisted 
on  going  out  or  killing  herself.  At  such  times  she  showed  an 
affectless,  impulsive  excitement.  Whether  there  was  an  element 
of  perplexity  then  is  not  clear  from  the  notes.  The  topics  of 
which  she  spoke  also  changed.  The  idea  of  wealth  was  rarely 
expressed,  also  the  idea  of  marriage  was  much  in  the  background, 
but  prominent  ideas  were  those  of  death.  Heaven,  killing  herself, 
going  to  Ireland — all  of  which  she  produced  in  an  affectless  way. 
It  should  be  added  that  she  persistently  wet  and  soiled  during 
this,  as  well  as  in  the  first  period. 

3.  Then  followed  three  months  of  greater  inactivity.  She  lay 
in  bed  gazing,  moving  very  little,  not  even  when  her  meals  were 
brought.  She  answered  but  little  and  consistently  wet  and  soiled. 
This  state  lasted  from  about  the  middle  of  February  until  the 
beginning  of  April. 


SPECIAL  CASES  173 

4.  From  this  stuporous  state  she  emerged  during  the  next 
four  weeks,  the  awakening  being  associated  with  persistent  efforts 
to  arouse  her.  She  then  was,  for  six  or  seven  weeks,  nearly 
normal,  so  far  as  her  mood  went,  but  had  a  tendency  to  cling  to 
some  of  her  ideas  and  was  overtalkative.  Her  memory  for  the 
earlier  phases  of  the  psychosis  was  good,  as  she  recalled  not  only 
many  external  events  but  most  of  her  false  ideas.  She  said, 
however,  that  her  mind  had  been  a  blank  for  the  third  stage  and 
she  remembered  nothing  of  it.  At  the  end  of  this  time  she  cleared 
up  entirely  and  was  discharged  as  "recovered."  She  continued 
well  for  some  months,  during  which  she  was  occasionally  ex- 
amined. 

This  case  gives  an  excellent  example  of  the  rela- 
tionship of  stupor  to  other  manic-depressive  reac- 
tions. She  begins  with  an  absorbed  state,  showing 
elements  of  perplexity  and  mania.  With  this  there 
are  expansive  ideas  but,  also,  statements  about 
losing  everything  and  being  in  prison,  which  sug- 
gest abandonment  of  life.  Next,  with  increasing 
apathy,  she  begins  to  speak  of  death  and  soon  makes 
impulsive  suicidal  attempts.  Evidently  her  mind 
was  becoming  more  and  more  focused  on  death  and 
with  this  there  was  an  appropriate  emotional 
change.  She  was  either  apathetic  or  the  affect  ex- 
hibited itself  in  pure  impulsiveness.  Then  comes 
the  stupor,  when  all  ideas  disappear  and  mentation 
is  reduced  or  absent.  When  the  stupor  lifts,  the 
original  ideas  appear  not  only  in  memory  but  occa- 
sion a  wavering  insight.  It  is  appropriate  that 
she  recalled  all  of  her  psychosis  fairly  well  with  the 
exception  of  the  pure  stupor,  which  she  remembered 
only  as  a  time  when  her  mind  was  a  blank. 


CHAPTER  IX 
THE  PHYSICAL  MANIFESTATIONS  OF  STUPOR 

We  must  now  discuss  the  most  difficult  of  all  the 
aspects  of  the  stupor  problem.  The  subject  is  so 
involved  and  the  evidence  so  inconclusive  that  ob- 
servers will  probably  interpret  the  phenomena  here 
reported  according  to  their  individual  preconcep- 
tions. What  we  have  to  say  is  therefore  published 
not  so  much  to  convince  as  to  stimulate  further 
work.  The  problem  is  wider  than  that  of  the  mere 
etiology  of  the  stupors  we  are  considering.  Their 
relationship  to  manic-depressive  insanity  is  so  inti- 
mate that  we  must  tentatively  consider  this  affect- 
less  reaction  as  belonging  to  that  larger  group.  A 
discussion  of  the  basic  pathology  of  manic-depres- 
sive insanity  is  outside  the  sphere  of  this  book.  The 
author,  therefore,  thinks  it  advisable  to  state  some- 
what dogmatically  his  view,  as  to  the  etiology  of 
these  affective  reactions,  merely  as  a  starting  point 
for  the  argument  concerning  stupors  specifically. 

It  is  our  view  that  the  manic-depressive  psychoses 
may  be,  and  probably  are,  determined  remotely  but 
fundamentally  by  an  inherent  neuropsychic  defect, 
but  this  physical  and  constitutional  blemish  is  non- 
specific.    The   actual   psychosis   is   determined  by 

174 


PHYSICAL  MANIFESTATIONS  OF  STUPOR    175 

functional,  that  is,  psychological  factors.  A  predis- 
posed individual  exposed  to  a  certain  psychic  stress 
develops  a  manic-depressive  psychosis.  Naturally 
any  physical  disease  reduces  the  capacity  for  nor- 
mal response  to  mental  difficulties;  hence  physical 
illness  may  facilitate  the  production  of  a  psychosis. 
But  this  intercurrent  factor  is  also  non-specific. 

Such  is  our  view  of  the  etiology  of  manic-depres- 
sive insanity  as  a  whole.  When  we  approach  the 
study  of  benign  stupors,  however,  difficult  problems 
appear.  As  will  be  discussed  in  a  later  chapter  on 
the  literature,  reactions  resembling  benign  stupors 
occur  as  a  result  of  toxins,  particularly  following 
acute  rheumatism.  Eecently  the  medical  profession 
has  been  called  on  to  treat  many  cases  of  encephali- 
tis lethargica  where  similar  symptoms  are  observed. 
If  the  resemblance  amounted  to  identity,  we  would 
have  to  admit  that  a  specific  toxin  may  produce  a 
specific  mental  reaction  which  we  have  concluded  on 
other  grounds  to  be  psychogenic.  As  a  matter  of  fact, 
in  two  particulars  these  reactions  show  relationship 
to  organic  delirium.  Knauer  reports  that  in  post- 
rheumatic stupors  illusions  are  frequent — an  ice 
bag  thought  to  be  a  cannon,  or  a  child,  etc. — and 
there  are  bizarre  misinterpretations  of  the  physical 
condition,  such  as  lying  on  glass  splinters,  animals 
crawling  on  the  body,  and  so  on.  Such  illusions  are, 
in  our  experience,  not  found  in  stupor,  and,  on  the 
other  hand,  are  cardinal  symptoms  of  delirium. 
Further,  Knauer  reports  that  even  at  the  height  of 
post-rheumatic  stupor,  external  stimuli  make  some 


176  BENIGN  STUPORS 

impression,  in  that  a  thoughtful  facial  expression 
appears.  In  deep  stupors,  such  as  occurred  in  our 
series,  this  response  is  not  seen.  The  same  phe- 
nomenon of  *^ rousing,''  larval  in  Knauer's  cases, 
is  often  well  marked  in  encephalitis  lethargica  and 
is,  of  course,  a  pathognomonic  symptom  of  delirium. 
We  might  therefore  think  that  these  conditions  are 
mixtures  of  two  organic  tendencies,  namely,  de- 
lirium and  coma.  It  is  not  impossible  that  resem- 
blances to  benign  stupor  are  due  to  functional  ele- 
ments appearing  in  the  reduced  physical  state  as 
additions  to  the  organic  symptoms.  The  promi- 
nence of  pain  might  be  taken  as  a  likely  cause  for 
an  instinctive  reaction  of  withdrawal,  which  would 
account  for  the  emotional  palsy  of  these  conditions 
on  psychogenic  grounds.  [This  argument  can  be 
better  understood  when  the  chapter  on  Psychological 
Explanation  of  Stupor  has  been  read.]  We  there- 
fore feel  justified  in  holding  that  the  resemblance 
of  the  symptoms  of  certain  plainly  organic  reactions 
to  those  of  benign  stupor  do  not  necessitate  a  split- 
ting of  these  stupors  from  the  manic-depressive 
group. 

When  we  consider  certain  bodily  manifestations 
of  these  typical  stupors,  however,  fresh  difficulties 
are  encountered.  Unlike  depressions,  elations  and 
anxieties,  certain  physical  symptoms  appear  with 
frequency,  even  regularity.  This  would  seem  to  in- 
dicate the  presence  of  physical  disease.  Inasmuch 
as  the  most  constant  of  them  is  fever,  the  natural 
conclusion  would  be  that  we  are  dealing  with  an 


PHYSICAL  MANIFESTATIONS  OF  STUPOR    177 

infection  which  produces  a  mental  state  called  stu- 
por. If  we  were  not  faced  with  an  obvious  relation- 
ship to  manic-depressive  insanity,  where  such  symp- 
toms are  usually  accidental  and  intercurrent,  we 
would  accept  this  explanation,  but  this  quandary  ne- 
cessitates further  analysis. 

Let  us  first  consider  the  fever.  In  35  cases,  on 
whom  data  of  temperature  could  be  found  from  the 
records  extant,  28  showed  fever  usually  running 
between  99°  and  100°,  often  up  to  101°  or  slightly 
over  this  point.  When  these  cases  were  analyzed, 
however,  it  was  found  that  27  were  typical  and  8 
atypical,  showing  pictures  resembling  those  de- 
scribed in  the  last  chapter.  Of  the  latter  only  one 
had  a  rise  of  temperature,  while  of  the  typical  group 
only  one  was  afebrile.  Therefore,  since  out  of  27 
typical  cases  26  had  the  typical  slight  fever,  we  must 
conclude  it  to  be  a  highly  specific  symptom.  Of 
these  28  cases  the  incidence  of  the  fever  was  as  fol- 
lows: 8  showed  it  only  on  admission;  in  7  it  was 
highest  on  admission  but  continued  at  a  low  rate 
throughout  the  rest  of  the  psychosis ;  in  5  it  extended 
without  much  variation  throughout  the  psychosis; 
in  4  it  appeared  intermittently,  while  in  2  it  was 
accentuated  during  periods  when  the  mental  symp- 
toms were  most  pronounced.  We  see,  then,  that 
there  is  a  distinct  tendency  for  the  fever  to  be  asso- 
ciated with  the  onset  of  the  disease. 

When  we  look  for  other  data  from  which  we  might 
discover  causes  for  the  fever,  we  find  less  than  we 
would  like.     The  records  are  of  observations  made, 


178  BENIGN  STUPORS 

some  of  them,  twenty  years  ago.  Although  the 
mental  examinations  were  careful,  the  records  of  the 
physical  symptoms  either  were  not  made  or  were 
lost  in  many  cases.  Consequently  our  description 
must  be  tentative  and  is  published  merely  to  stimu- 
late further  research  as  cases  come  to  the  attention 
of  psychiatrists. 

One  looks,  first,  for  other  evidence  of  infection. 
Some  of  the  cases  were  thoroughly  examined  with 
modern  methods  and  nothing  whatever  found. 
Blood  examinations  were  made  in  five  cases;  three 
of  these  had  rather  high  temperature  with  the  fol- 
lowing blood  pictures :  Charles  0.,  103°,  leucocytosis 
of  23,000,  with  91.5%  polymorphonuclears;  Annie  Gr. 
(Case  1),  103°,  leucocytosis  of  12,000  to  15,000,  and 
89%  polymorphonuclears;  Caroline  DeS.  (Case  2), 
104°,  15,000  leucocytes,  no  differential  made,  Widal 
and  diazo  reaction  negative.  These  three  cases, 
then,  had  marked  febrile  reactions  and  leucocytosis. 
It  is  quite  possible  that  they  had  infections  which 
were  not  discovered.  Of  the  other  two  Rosie  K. 
(Case  11)  had  a  temperature  of  100°  and  17,500 
leucocytes  associated  with  a  fetid  diarrhea,  an  un- 
questioned infection,  while  Mary  C.  (Case  7),  with 
a  temperature  of  only  100°,  had  no  rise  in  number 
of  total  white  cells  but  41%  of  lymphocytes.  This 
last  might  be  due  to  an  internal  secretion  or  an  in- 
voluntary nervous  system  anomaly.  The  possi- 
bility of  the  three  high  temperatures  with  leucocy- 
tosis being  due  to  intercurrent  infections  must  be 
considered.     Charles  0.  had  high  fever  only  for  ten 


PHYSICAL  MANIFESTATIONS  OF  STUPOR    179 

days  during  a  psychosis  of  several  months.  Annie 
Gr.'s  high  fever  was  of  about  the  same  duration. 
Caroline  DeS.  had  short  periods  of  marked  pyrexia 
in  the  first  and  seventh  months  of  her  long  psycho- 
sis. Except  for  these  episodes,  these  three  patients 
had  the  typical  slight  elevation  of  temperature. 
Three  cases  out  of  thirty -five,  in  which  high  fever  and 
leucocytosis  appeared  episodically,  are  hardly 
enough  to  justify  the  view  that  stupors  are  the  result 
of  a  specific  infection.  We  must  remember,  too,  that 
no  focal  neurological  symptoms  are  ever  observed, 
which  makes  the  possibility  of  a  central  nervous 
system  infection  highly  unlikely. 

An  alternative  view  might  be  that  the  slight  rise 
of  fever  is  somehow  the  result  of  stupor,  not  the 
cause  of  it.  The  editor  consulted  Professor  Charles 
R.  Stockard,  of  Cornell  Medical  College,  as  to  this 
possibility.  The  following  argument  is  the  result 
of  his  suggestions : 

What  we  call  a  normal  temperature  is,  of  course, 
the  result  of  a  balance  maintained  between  heat  pro- 
duction and  heat  loss.  Either  an  increase  in  the 
former  or  a  decrease  in  the  latter  must  produce 
fever.  It  is  possible  that  heat  production  may  be 
increased  in  many  stupors  as  a  result  of  the  mus- 
cular rigidity.  Some  cases  showed  higher  tempera- 
ture when  this  was  more  marked,  but  this  was  not 
sufficiently  constant  to  justify  any  conclusions  being 
drawn. 

Heat  loss  occurs  preponderantly  as  a  result  of  ra- 
diation from  the  skin  and  by  sweating  with  conse- 


180  BENIGN  STUPORS 

quent  evaporation  of  the  secretion.  These  processes 
are  functions  of  the  skin  and  surface  circulation. 
Are  they  disturbed  in  our  stupors?  We  find  con- 
siderable evidence  that  they  are.  Flushing  or  der- 
matographia  occurred  in  six  cases,  cold  or  blue 
extremities  in  four  cases,  greasy  skin  in  four, 
marked  sweating  in  three,  the  hair  fell  out  in  two 
cases,  while  the  skin  was  pathologically  dry  in  one 
case,  in  fact  there  were  few  patients  who  showed 
normal  skin  function.  Circulatory  anomalies  were 
also  observed.  The  pulse  was  very  rapid  in  eleven 
cases,  weak  or  irregular  in  two,  and  slow  in  one 
case.  All  these  symptoms  are  expressions  of  im- 
balance in  the  involuntary  nervous  system,  further 
evidence  of  which  is  found  in  the  rapid  respiration 
of  six  cases  and  the  shallow  breathing  of  one  patient. 
These  pulse  and  respiration  findings  are  the  more 
striking  in  that  individuals  in  stupor  are,  by  the 
very  nature  of  their  disease,  free  from  emotional 
excitement. 

This  imbalance  could  result  from  a  poverty  of  cir- 
culating adrenalin  which  is  necessary  for  the  activa- 
tion of  the  sympathetic  nerves.  A  cause  for  low 
suprarenal  function  is  to  be  found  in  the  apathy  of 
the  stupor  case.  As  Cannon  and  his  associates  have 
so  conclusively  demonstrated,  any  emotion  which 
was  open  to  investigation  resulted  in  an  increase  of 
adrenalin  output.  As  our  emotions  are  constantly 
operating  during  the  day — and  often  enough  during 
sleep  as  well  in  connection  with  dreams — ^we  must 
presume  that  emotional  stimulus  is  a  normal  excitant 


PHYSICAL  MANIFESTATIONS  OF  STUPOR    181 

for  the  production  of  adrenalin.  It  is  therefore  in- 
conceivable that  the  blood  could  receive  its  normal 
supply  of  adrenalin  with  an  apathy  of  the  degree 
seen  in  stupor  unless  some  purely  hypothetically 
substitutive  excitant  were  found. 

We  may  therefore  tentatively  assume  that  the 
fever  which  marks  the  onset  and  frequently  the 
course  of  these  benign  stupors  is  the  result  of  a 
failure  of  the  heat  loss  function,  this  being  due  to 
an  imbalance  in  the  involuntary  nervous  system  that 
is  occasioned,  in  turn,  by  insufficient  circulating  ad- 
renalin, and  the  final  cause  for  the  poor  suprarenal 
function  is  to  be  traced  to  the  most  consistent  symp- 
tom of  the  stupor,  namely,  apathy.  This  hypothesis 
is  welcome,  not  only  because  it  would  account  ade- 
quately for  the  fever,  but  it  also  tends  to  accentuate 
the  relationship  with  other  forms  of  manic-de- 
pressive insanity,  all  of  which  are  marked  fun- 
damentally by  a  pathological  emotion.  Naturally 
enough,  one  turns  to  the  records  again  to  see  if  the 
blood-pressure  of  these  patients  was  low,  as  would 
be  expected  with  a  poor  adrenalin  supply.  Un- 
fortunately record  was  made  of  the  blood-pressure 
in  only  two  cases,  in  both  of  which  the  reading  was 
110  m.m.  Two  such  isolated  observations  mean,  of 
course,  nothing  whatever.  It  is  possible  that  the 
drooling  which  so  many  stupor  cases  show  is  not 
merely  the  result  of  the  failure  of  the  swallowing 
reflex,  but  represents  as  well  a  compensation  for 
anhydrosis  by  excessive  salivary  secretion. 

Another  symptom  suggestive  of  involuntary  ner- 


182  BENIGN  STUPOES 

vous  system  or  endocrine  disorder  is  the  highly  fre- 
quent suppression  of  the  menstrual  function.  At 
times  this  may  occur  as  a  sequel  to  mental  shock, 
as  it  did  in  the  case  of  Celia  H.  (Case  19),  who  was 
menstruating  when,  frightened  by  the  suicidal  at- 
tempt of  her  brother,  the  flow  ceased  abruptly. 
That  purely  psychic  factors  can  produce  marked 
changes  in  such  functions  has  been  demonstrated  by 
Forel  and  other  hypnotists  time  and  again ;  presum- 
ably the  effect  is  produced  by  way  of  alteration  in 
the  endocrine  or  involuntary  nervous  system  influ- 
ence. In  such  cases,  however,  we  can  trace  the  men- 
strual suppression  directly  to  an  emotional  cause. 
On  the  other  hand,  most  women  in  stupor  fail  to 
menstruate  during  the  bulk  of  the  psychosis  at  a  time 
when  we  believe  emotions  to  be  absent  or  greatly  re- 
duced in  their  intensity.  The  recent  work  of  Pa- 
panicolaou and  Stockard  ^  otfers  a  simple  explana- 
tion for  this  phenomenon.  They  have  shown  that 
in  the  guinea  pig  the  oestrous  cycle  can  be  delayed 
by  starvation,  while  in  weaker  animals  a  period  may 
be  suppressed  completely.  When  one  considers  that 
even  with  the  greatest  care  the  nutrition  of  tube- 
fed  patients  is  bound  to  be  poor,  it  would  be  only 
natural  to  suppose  that  this  malnutrition  would 
cause  such  a  disturbance  in  the  cestrous  cycle  and 
was  evidenced  objectively  by  a  failure  to  menstru- 

^ Papanicolaou,  G.  N.,  and  Stockard,  C.  E.,  ''Effect  of  Under- 
feeding on  Ovulation  and  the  CEstrous  Ehythm  in  Guinea-pigs.'' 
Proceedings  of  the  Society  of  Experim^ental  Biology  and  Medicine, 
Vol.  XVII,  No.  7,  Apr.  21,  1920. 


PHYSICAL  MANIFESTATIONS  OF  STUPOR    183 

ate.  Even  in  patients  who  are  not  tube-fed,  under- 
nutrition is  to  be  expected  and,  as  a  matter  of  fact,  is 
usually  observed.  The  work  of  Pawlow  and  Cannon 
has  shown  how  essential  psychic  stimulus  is  for  gas- 
tric digestion.  Any  condition  of  apathy  would 
therefore  tend  to  retard  digestion  and  indirectly  af- 
fect nutrition. 

Finally,  under  the  heading  of  Physical  Manifesta- 
tions of  Stupor,  we  must  consider  epileptoid  attacks, 
of  which  there  was  a  history  in  two  of  our  cases, 
both  of  which  have  already  been  described  in  the 
first  chapter  of  this  book.  Anna  G.  (Case  1),  in  her 
second  attack,  was  treated  at  another  hospital,  and 
from  the  account  which  they  sent  it  appears  that 
the  stupor  was  immediately  preceded  by  a  seizure 
in  which  the  whole  body  jerked.  This  is,  of  course, 
rather  thin  evidence  of  the  existence  of  a  definite 
convulsion,  but  in  the  case  of  Mary  F.  (Case  3)  we 
have  a  fuller  description.  During  the  two  days 
when  the  stupor  was  incubating,  she  had  repeated 
seizures  of  the  following  nature.  She  sometimes 
said  that  prior  to  the  attacks  it  became  dark  before 
her  eyes  and  that  her  face  felt  funny  or  that  she  had 
a  pain  in  the  stomach  which  worked  toward  her  right 
shoulder.  The  attack  would  begin  when  sitting  in 
a  chair,  with  the  closing  of  her  eyes,  clenching  her 
fists  and  pounding  the  side  of  the  chair.  She  would 
then  get  stiff  and  slide  on  to  the  floor,  where  she 
would  thrash  her  arms  and  legs  about  and  move  her 
head  to  and  fro.  The  warning  of  the  pain  working 
from  the  stomach  to  the  right  shoulder  is  highly 


184  BENIGN  STUPORS 

suggestive  of  an  epileptic  aura,  although  the  other 
symptoms  mentioned  so  far  could  have  been  con- 
sidered hysterical  or  poorly  described  epileptic  phe- 
nomena. The  rest  of  the  description  indicates  an 
epileptic  seizure  more  strongly.  She  frothed  at  the 
mouth  and  once  wet  herself  during  an  attack.  They 
lasted  only  for  a  few  minutes  and  she  would  breathe 
heavily  after  them.  At  the  end  of  one  attack  she 
wiped  the  froth  from  her  mouth  with  her  handker- 
chief and  gave  it  to  her  aunt,  saying,  ^  *  Bum  that,  it 
is  poison.''  This  is  perhaps  a  little  less  like  epi- 
lepsy. It  is  plainly  impossible  for  us  to  say  with 
any  positiveness  that  either  these  were  or  were  not 
genuine  convulsions,  but  it  is  nevertheless  important 
to  record  them,  because  such  phenomena  are  ob- 
served fairly  frequently  in  dementia  prsecox  cases 
but  are  practically  unknown  in  manic-depressive  in- 
sanity. This,  then,  would  be  another  example  of 
the  resemblance  to  dementia  prsecox  in  these  stupors 
which  are  unquestionably  benign.^ 

*  As  a  matter  of  fact,  if  the  views  of  Clark  and  MacCurdy  *  be 
a,ccepted,  some  reason  for  these  epileptic-like  attacks  may  be  imag- 
ined. According  to  them,  epilepsy  is  a  disease  characterized  by  a 
lack  of  the  natural  instinctive  interest  in  the  environment  which 
is  expressed  chronically  in  the  deterioration,  and  episodically  in 
the  attacks,  the  most  consistent  feature  of  which  is  loss  of  con- 
sciousness. Now,  in  stupor  we  have  an  analogous  reaction  where, 
although  consciousness  is  not  disturbed  in  the  sense  in  which  it  is 

*  Clark,  L.  Pierce.  ' '  Is  Essential  Epilepsy  a  Life  Reaction  Dis- 
order?" Am.  Jour,  of  the  Medical  Sciences,  November,  1910,  Vol. 
CLVIII,  No.  5,  p.  703.  This  paper  gives  a  summary  of  Dr.  Clark's 
theories. 

MacCurdy,  John  T.,  ''A  Clinical  Study  of  Epileptic  Deteriora- 
tion."    Psychiatric  Bulletin,  April,  1916. 


PHYSICAL  MANIFESTATIONS  OF  STUPOR    185 

We  see,  then,  in  reviewing  all  the  physical  mani- 
festations of  the  benign  stupors,  that  none  occurred 
which  cannot  be  explained  as  secondary  to  the  men- 
tal changes,  and  therefore,  until  such  time  as  physi- 
cal symptoms  are  reported  which  cannot  be  so  ex- 
plained, we  see  no  reason  for  changing  our  view 
that  the  benign  stupor  is  to  be  regarded  as  one  of 
the  manic-depressive  reactions. 

in  epilepsy,  it  is  nevertheless  considerably  affected,  inasmuch  as 
contact  with  the  environment  is  practically  non-existent.  The  coin- 
cident thinking  disorder  is  quite  similar,  both  in  epileptic  dementia 
and  the  torpor  following  seizures  and  in  these  benign  stupors.  Mac- 
Curdy  has  suggested  tentatively  that  the  epileptic  convulsion  may 
be  secondary  to  a  very  sudden  loss  of  consciousness  which  removes 
a  normal  inhibition  on  the  muscles,  liberating  the  muscular  con- 
tractions which  constitute  the  convulsion.  If  this  view  were  correct, 
it  would  not  be  hard  to  imagine  that  during  the  onset  of  these 
stupors  the  tendency  to  part  company  with  the  environment,  which 
ordinarily  comes  on  slowly,  might  occur  with  epileptic  suddenness 
and  hence  liberate  convulsive  movements.  This  is,  however,  a  pure 
speculation  but  not  fruitless  if  it  serves  to  draw  attention  to  the 
analogies  existing  between  the  stupor  reaction  and  some  of  the  men- 
tal symptoms  of  epilepsy.  These  analogies  are  strong;  aside  from 
the  obvious  clinical  differences,  the  stupor  and  epileptic  reactions 
are  dynamically  unlike  in  that  they  are  the  product  of  different 
temperaments  and  precipitated  by  different  situations. 


CHAPTER  X 

PSYCHOLOGICAL  EXPLANATION  OF  THE  STUPOR 

REACTION 

In  the  previous  chapter  niention  has  been  made 
of  our  view  that  manic-depressive  insanity  is  a 
disease  fundamentally  based  on  some  constitu- 
tional defect,  presumably  physical,  but  that  its 
symptoms  are  determined  by  psychological  mecha- 
nisms. In  accordance  with  this  hypothesis  we  seek, 
when  studying  the  different  forms  of  insanity  pre- 
sented in  this  group,  to  differentiate  between  the 
different  types  of  mental  mechanisms  observed,  and 
by  this  analysis  to  account  for  the  manifestations  of 
the  disease  on  purely  psychological  lines.  If  be- 
nign stupors  belong  to  this  group,  then  we  should 
be  able  to  find  some  specific  psychology  for  this  type 
of  reaction. 

All  speech  and  all  conduct,  except  simple  reflex  be- 
havior, are  presumably  determined  by  ideas.  When 
an  individual  is  not  aware  of  the  purpose  governing 
his  action,  we  assume,  in  psychological  study,  that  an 
unconscious  motive  is  present,  so  that  in  either  case 
the  first  step  in  psychological  understanding  of  any 
normal  or  abnormal  condition  is  to  discover,  if 
possible,  what  the  ideas  are  that  lead  to  the  actions 

186 


EXPLANATION  OF  THE  STUPOR  REACTION     187 

or  utterances  observed.  In  the  case  of  stupors  the 
situation  is  fairly  simple,  in  that  the  ideational  con- 
tent is  extremely  limited.  As  has  been  seen,  it  is 
confined  to  death  and  rebirth  fancies,  other  ideas  be- 
ing correlated  with  secondary  symptoms,  such  as 
belong  to  mechanisms  of  other  manic-depressive 
psychoses.  It  is  not  necessary  to  repeat  the  cata- 
logue of  the  typical  stupor  ideas,  as  they  have  been 
given  in  an  earlier  chapter.  Our  task  is  now  to 
consider  the  significance  of  these  death  and  rebirth 
delusions  and  their  meaning  for  the  stupor  reaction. 

Thoughts  concerned  with  future  and  new  activities 
require  energy  for  their  completion  in  action  and 
are  therefore  naturally  accompanied  by  a  sense  of 
effort  which  gives  pleasure  to  an  active  mind.  When 
the  sum  of  energy  is  reduced,  one  observes  a  re- 
verse tendency  called  ''regression."  It  is  easier  to 
go  back  over  the  way  we  know  than  to  go  forward, 
so  the  weakened  individual  tends  to  direct  his  at- 
tention to  earlier  actions  or  situations.  To  meet  a 
new  experience  one  must  think  logically  and  keep 
his  attention  on  things  as  they  are,  rather  than  imag- 
ine things  as  one  would  like  to  have  them. 

Progressive  thinking  is  therefore  adaptive,  while 
regressive  thinking  is  fantastic  in  type,  as  well  as 
concerned  with  the  past^ — a  past  which  in  fancy  takes 
on  the  luster  of  the  Golden  Age.  Sanity  and  in- 
sanity are,  roughly  speaking,  states  where  progres- 
sive or  regressive  thinking  rule.  The  essence  of  a 
functional  psychosis  is  a  flight  from  reality  to  a  re- 
treat of  easeful  unreality. 


188  BENIGN  STUPORS 

Carried  to  the  extreme,  regression  leads  one  in 
type  of  thinking  and  in  ideas  back  to  childhood  and 
earliest  infancy.  The  final  goal  is  a  state  of  mental 
vacuity  such  as  probably  characterizes  the  infant  at 
the  time  of  birth  and  during  the  first  days  of  ex- 
tra-uterine life.  In  this  state  what  interest  there  is, 
is  directed  entirely  to  the  physical  comfort  of  the 
individual  himself,  and  contact  with  the  environment 
is  so  undeveloped  that  efforts  to  obtain  from  it  the 
primitive  wants  of  warmth  and  nutrition  are  con- 
fined to  vague  instinctive  cries.  Evolution  to  true 
contact  with,  the  world  around  implies  effort,  the 
exercise  of  self-control,  and  also  self-sacrifice,  since 
the  child  soon  learns  that  some  kind  of  quid  pro  quo 
must  be  given.  Viewed  from  the  adult  standpoint, 
the  emptiness  of  this  early  mental  state  must  seem 
like  the  Nirvana  of  death.  At  least  death  is  the 
only  simple  term  we  can  use  to  represent  such  a  com- 
plete loss  of  our  habitual  mental  functions.  When 
life  is  difficult,  we  naturally  tend  to  seek  death. 
Were  it  not  for  the  powerful  instinct  of  self-preser- 
vation, suicide  would  probably  be  the  universal  mode 
of  solving  our  problems.  As  it  is,  we  reach  a  com- 
promise, such  as  that  of  sleep,  in  which  contact  with 
reality  is  temporarily  abandoned.  In  so  far  as  sleep 
is  psychologically  determined,  it  is  a  regressive  phe- 
nomenon. It  is  interesting  that  the  most  frequent 
euphemism  or  metaphor  for  death  is  sleep.  Sleep 
is  a  normal  regression.  It  does  not  always  give  the 
unstable  individual  sufficient  relaxation  from  the  de- 
mands of  adaptation  and  so  pathological  regressions 


EXPLANATION  OF  THE  STUPOR  REACTION    189 

take  place,  one  of  which  we  believe  stupor  to  be. 
It  is  important  to  note  that  objectively  the  resem- 
blance between  sleep  and  stupor  is  striking.  So  far 
as  mental  activity  in  either  state  can  be  discovered 
by  the  observer,  either  the  sleeper  or  the  patient  in 
stupor  might  be  dead.  Briefly  stated,  then,  our  hy- 
pothesis of  the  psychological  determination  of  stu- 
por is  that  the  abnormal  individual  turns  to  it  as  a 
release  from  mental  anguish,  just  as  the  normal 
human  being  seeks  relief  in  his  bed  from  physical 
and  mental  fatigue.  When  this  desire  for  refuge 
takes  the  shape  of  a  formulated  idea,  there  are  delu- 
sions of  death. 

The  problem  of  sleep  is,  of  course,  bound  up  with 
the  physiology  of  rest,  and  as  recuperation,  in  a 
physical  sense,  necessitates  temporary  cessation  of 
function,  so  in  the  mental  sphere  we  see  that  relaxa- 
tion is  necessary  if  our  mental  operations  are  to  be 
carried  on  with  continued  success.  This  is  prob- 
ably the  teleological  meaning  of  sleep  in  its  psycho- 
logical aspects,  for  in  it  we  abandon  diurnal  adaptive 
thinking  and  retire  to  a  world  of  fancy,  very  often 
solving  our  problems  by  ^^ sleeping  over  them." 
The  innate  desire  for  rest  and  a  fresh  start  is  al- 
most as  fundamental  a  human  craving  as  is  the  ten- 
dency to  seek  release  in  death.  In  fact  the  two  are 
closely  associated  both  in  literature  and  in  daily 
speech,  for  in  many  phases  we  correlate  death  with 
new  life.  If  one  is  to  visualize  or  incorporate  the 
conception  of  new  life  in  one  term,  rebirth  is  the 
only  one  which  will  do  it,  just  as  death  is  the  only 


190  BENIGN  STUPORS 

word  which  epitomizes  the  idea  of  complete  cessation 
of  effort.  Not  unnaturally,  therefore,  we  find  in 
the  mythology  of  our  race,  in  our  dreams  and  in  the 
speech  of  our  insane  patients,  a  frequent  correlation 
of  these  two  ideas,  whether  it  comes  in  the  crude 
imagery  of  physical  rebirth  or  projected  in  fan- 
tasies of  destruction  and  rebuilding  of  the  world. 
Many  of  our  psychotic  patients  achieve  in  fancy  that 
for  which  the  Persian  poet  yearned : 

"Ah  Love!  could  you  and  I  with  Him  conspire 
To  grasp  this  Sorry  Scheme  of  Things  entire, 
Would  we  not  shatter  it  to  bits — and  then 
Re-mold  it  nearer  to  the  Heart's  Desire!" 

A  vision  of  a  new  world  is  a  content  occurring  not 
infrequently  in  manic  states,  but  before  the  universe 
can  be  remolded  it  must  be  destroyed.  Before  the 
individual  can  enjoy  new  life,  a  new  birth,  he  must 
die,  and  stupor  often  marks  this  death  phase  of  a 
dominant  rebirth  fantasy.  In  this  connection  it 
was  not  without  significance  to  note  that  stupors 
almost  universally  recover  by  way  of  attenuation 
of  the  stupor  symptoms,  or  in  a  hypomanic  phase 
where  there  seems  to  be  an  abnormal  supply  of  en- 
ergy. Antaeus-like,  they  rise  with  fresh  vigor  from 
the  Earth.  They  do  not  pass  into  depressions  or 
anxieties. 

Eebirth  fancies  unquestionably,  then,  contain 
constructive  and  progressive  elements,  but,  as  has 
been  stated  above,  any  thinking  which  implies  a 
lapse  of  contact  with  the  environment  is,  in  so  far 


EXPLANATION  OF  THE  STUPOK  REACTION     191 

as  that  lapse  is  concerned,  regressive,  and  in  conse- 
quence rebirth  fancies,  as  dramatized  by  the  stupor 
patients,  are  regressive,  just  as  are  the  delusions 
of  death  itself. 

It  is  obvious  that  an  acceptance  of  death  implies 
rather  thorough  mental  disintegration.  Before  that 
takes  place  there  may  be  some  mental  conflict.  The 
instinct  of  self-preservation  may  prevent  the  indi- 
vidual from  welcoming  the  notion  of  dissolution,  so 
that  this  latter  idea,  though  insistent,  is  not  accepted 
but  reacted  to  with  anxiety;  hence  we  often  meet 
with  onsets  of  stupor  characterized  by  emotional 
distress.  It  has  already  been  suggested  that  death 
may  foreshadow  another  existence.  Often  in  the 
psychoses  we  meet  with  the  idea  of  eternal  union 
in  death  with  some  loved  one  whom  the  vicissitudes 
and  restrictions  of  this  life  prevent  from  becoming 
an  earthly  partner.  This  fancy  is  frequently  the 
basis  of  elation.  Similarly,  new  life  in  a  religious 
sense  as  expressed  in  the  delusion  of  translation  to 
Heaven,  is  a  common  occasion  for  ecstasy.  These 
formulations  of  the  death  idea  may  occur  as  tenta- 
tive solutions  of  the  patient's  problems  leading  to 
temporary  manic  episodes  while  the  psychosis  is  in- 
cubating. It  seems  that  stupor  as  such  appears 
only  when  death  and  nullity  are  accepted. 

The  above  are  more  or  less  a  priori  reasons  for 
regarding  the  stupor  as  a  regressive  reaction.  We 
must  now  consider  the  clinical  evidence  to  support 
this  view.  In  the  first  place,  we  always  find  that 
stupor  occurs  in  an  individual  who  is  unhappy  and 


192  BENIGN  STUPORS 

wlio  has  found  no  other  solution  than  regression 
for  the  predicament  in  which  he  is.  There  is  noth- 
ing specific  in  the  cause  of  this  unhappiness.  At 
times  the  factors  producing  it  are  mainly  environ- 
mental; at  others,  the  problem  is  essentially  of  the 
patient's  own  making.  Of  course  almost  any  type 
of  functional  psychosis  may  emerge  from  such  a 
state  of  dissatisfaction,  but  it  is  important  to  note 
that  unlike  manic  states,  for  instance,  stupors  in- 
variably develop  from  a  situation  of  unhappiness. 
Quite  frequently  the  choice  of  the  stupor  regression 
is  determined  by  some  definitely  environmental  event 
which  suggests  death.  This  often  comes  as  the  ac- 
tual death  of  the  patient's  father  (in  the  case 
of  a  woman)  or  employer,  events  which  inflate  the 
already  existing,  although  perhaps  unconscious,  de- 
sire for  mutual  death.  Again,  the  precipitating 
factor  may  be  a  situation  which  adds  still  another 
problem  and  makes  the  burden  of  adaptation  intol- 
erable, forcing  on  him  the  desire  for  death.  In  these 
cases  the  actual  psychosis  is  sometimes  ushered  in 
dramatically  with  a  vision  of  some  dead  person 
(often  a  woman's  father)  who  beckons,  or  there  are 
dream-like  experiences  of  burial,  drowning,  and 
so  on. 

A  few  cases  taken  at  random  from  our  material 
exemplify  these  features  of  the  unhappiness  in 
which  the  psychosis  appears  as  a  solution  with  its 
development  of  the  death  fancy. 

Alice  E.,  at  the  age  of  25,  was  much  troubled 
by  worrying  over  her  financial  difficulties  and  the 


EXPLANATION  OF  THE  STUPOR  REACTION     198 

shame  of  an  illegitimate  child.  Eetrospectively  she 
stated,  ''I  was  so  disgusted  I  went  to  bed — I  just 
gave  up  hope.''  Shortly  before  admission  she  said 
she  was  lost  and  damned,  and  to  the  nurse  in  the 
Observation  Pavilion  she  pleaded,  *^ Don't  let  me 
murder  myself  and  the  baby." 

Caroline  DeS.  (Case  2)  for  some  time  was  worried 
over  the  engagement  of  her  favorite  brother  to  a 
Protestant  (herself  a  Catholic)  and  the  threatened 
change  of  his  religion.  At  his  engagement  dinner 
she  had  a  sudden  excitement,  crying  out,  ^  ^  I  hate  her 
— I  love  you — ^papa,  don't  kill  me."  This  excite- 
ment lasted  for  three  weeks,  during  two  of  which 
she  was  observed,  when  she  spoke  frequently  of  be- 
ing killed  and  going  to  Heaven.  The  conflict  was 
frankly  stated  in  the  words,  **I  love  my  father  but 
don't  want  to  die."  Then  for  two  weeks  she  had 
some  fever,  was  tube-fed,  muttered  about  being 
killed  or  showed  some  elation,  there  being  appar- 
ently interrupted  stuporous,  manic  and,  possibly, 
anxiety  episodes.  Finally  she  settled  down  to  a 
year  of  deep  stupor. 

Laura  A.  had  for  three  months  poor  sleep  with 
depression  over  her  failure  in  study.  Another 
cause  for  worry  was  that  her  father  was  home  and 
out  of  work.  She  reached  a  point  where  she  did 
not  care  what  happened  but  continued  working. 
Ten  days  before  admission  she  was  not  feeling  well. 
The  next  morning  she  woke  up  confused  and  fright- 
ened, speedily  became  dazed,  stunned,  could  not 
bring  anything  to  her  memory.     This  rather  sudden 


194  BENIGN  STUPORS 

stupor  onset  was  not  accompanied  by  any  false  ideas, 
at  least  none  which  the  family  remembered. 

Mary  C.  (Case  7)  was  an  immigrant  who  felt 
lonely  in  the  new  country.  Two  weeks  before  ad- 
mission her  uncle  with  whom  she  was  living  died. 
She  thought  she  had  brought  bad  luck,  complained 
of  weakness  and  dizziness,  then  suddenly  felt  mixed 
up,  her  ''memory  got  bad,"  and  she  thought  she  was 
going  to  die.  Next  she  was  frightened,  heard  voices, 
thought  there  was  shooting  and  a  fire.  For  a  short 
time  she  was  inactive  and  later  began  shouting 
''Fire!"  When  taken  to  the  Observation  Pavilion, 
she  was  dazed,  uneasy,  thought  she  was  on  a  boat  or 
shut  up  in  a  boat  which  had  gone  down;  all  were 
drowned.    Then  came  a  mild  stupor. 

Maggie  H.  (Case  14),  while  pregnant,  fancied 
that  her  baby  would  be  deformed  and  that  she  would 
die  in  childbirth.  Three  weeks  before  admission 
this  event  took  place.  For  ^ve  days  she  worried 
about  not  having  enough  milk,  about  her  husband 
losing  his  job  (he  did  lose  it)  and  thought  her  head 
was  getting  queer.  On  the  fifth  day  she  cried,  said 
she  was  going  to  die,  that  there  was  poison  in  the 
food,  that  her  husband  was  untrue  to  her.  She  be- 
came mute  but  continued  to  attend  to  her  baby.  She 
saw  dead  bodies  lying  around,  and  by  the  time  she 
was  taken  to  the  Observation  Pavilion  was  in  a 
marked  stupor. 

Turning  now  to  the  symptoms  of  the  stupor 
proper,  we  note,  first,  the  effects  of  the  loss  of  en- 
^ergy  wMoh  regression  implies.    The  inactivity  and 


EXPLANATION  OF  THE  STUPOR  REACTION    195 

apathy  wMch  these  patients  show  is  too  obviously 
evidence  of  this  to  require  further  comment.  An- 
other proof  of  the  withdrawal  of  the  libido  or  in- 
terest is  found  in  the  thinking  disorder.  Directed, 
accurate  thinking  requires  effort,  as  we  all  know 
from  the  experience  of  our  laborious  mistakes  when 
fatigued.  So  in  stupor  there  is  an  inability  to  per- 
form simple  arithmetical  problems,  poor  orientation 
is  observed,  and  so  on.  Similarly  what  we  remem- 
ber seems  to  be  that  which  we  associate  with  the 
impressions  received  by  an  active  consciousness. 
Actual  events  persist  in  memory  better  than  those 
of  fancy,  in  proof  of  which  one  thinks  at  once  of 
the  vanishing  of  dreams  on  waking,  with  its  reestab- 
lishment  of  extroverted  consciousness.  This  regis- 
tration of  impressions  requires  interest  and  active 
attention.  Without  interest  there  is  no  attention 
and  no  registration.  The  patient  in  stupor  presents 
just  the  memory  defect  which  we  would  expect.  In- 
difference to  his  environment  leads  to  a  poor  mem- 
ory of  external  events,  while  on  recovery  there  may 
be  such  a  divorce  between  consciousness  of  normal 
and  abnormal  states  that  the  past  delusions  are 
wiped  from  the  record  of  conscious  memory.  With- 
drawal of  energy  then  produces  not  only  inactivity 
and  apathy  but  grave  defects  in  intellectual  capacity. 
The  natural  flow  of  interest  in  regression  is  to 
earlier  types  of  ambition  and  activity.  This  is  be- 
trayed not  merely  by  the  thought  content  dealing 
with  the  youth  and  childhood  of  the  patient,  but  also 
is   manifested   in   behavior.     Excluding   involution 


196  BENIGN  STUPORS 

melancholia  there  is  probably  no  psychosis  in  which 
the  patients  exhibit  such  infantile  reactions  as  in 
stupor.  Except  for  the  stature  and  obvious  age  of 
these  patients,  one  could  easily  imagine  that  he  was 
dealing  with  a  spoiled  and  fractious  infant.  One 
thinks  at  once  of  the  negativism  which  is  so  like 
that  of  a  perverse  child  and  of  the  unconventional, 
personal  habits  to  which  these  patients  cling  so  stub- 
bornly. Masturbation,  for  instance,  is  quite  fre- 
quent, while  willful  wetting  and  soiling  is  still  more 
common.  We  sometimes  meet  with  childishness, 
both  in  vocabulary  and  mode  of  expression.  In  one 
case  there  was  evidently  a  delusion  of  a  return  to 
actual  childhood,  for  she  kept  insisting  that  she  was 
''in  papa's  house.'' 

The  frequency  with  which  the  delusion  of  mutual 
death  occurs  in  stupor  is  another  evidence  of  its 
regressive  psychology.  The  partner  in  the  spiritual 
marriage  is  rarely,  if  ever,  the  natural  object  of 
adult  affection,  but  rather  a  parent  or  other  relative 
to  whose  memory  the  patient  has  unconsciously 
clung  for  many  years,  reawakening  in  the  psychosis 
an  ambition  of  childhood  for  an  exclusive  possession 
that  reaches  its  fulfillment  in  this  delusion.  Closely 
allied  with  this  is  another  delusion,  that  of  being 
actually  dead,  which  the  patients  sometimes  express 
in  action,  even  when  not  in  words.  The  anesthesia 
to  pin  pricks,  the  immobility  and  the  refusal  to  rec- 
ognize the  existence  of  the  world  around,  in  patients 
who  give  evidence  of  some  iatellectual  operations 
still  persisting,  are  probably  all  part  of  a  feigned 


EXPLANATION  OF  THE  STUPOR  REACTION    197 

death,  with  the  delusion  expressing  itseK  in  corpse- 
like behavior. 

Finally  we  must  consider  the  meaning  of  the  deep 
stupor  where  no  mentation  of  any  kind  can  be  proven 
and  where  none  but  vegetative  functions  seem  to  be 
operating.  This  state  is  either  one  of  organic  coma, 
in  which  case  it  marks  the  appearance  of  a  physical 
factor  not  evidenced  in  the  milder  stages,  or  else  it 
is  the  acme  of  this  regression  by  withdrawal  of  in- 
terest. As  has  been  stated,  back  of  the  period  of 
primitive  childish  ideas  there  lies  a  hypothetical 
state  of  mental  nothingness.  If  we  accept  the  prin- 
ciple of  regression  we  find  historically  an  analogue 
to  what  is  apparently  the  mental  state  of  deep  stu- 
por in  the  earliest  phases  of  infancy.  This  view  re- 
ceives justification  from  the  study  of  the  phenome- 
non of  variations  in  symptoms.  Mental  faculties  at 
birth  are  larval,  and  if  such  condition  be  artificially 
produced  mental  activity  must  be  potentially  pres- 
ent (as  it  would  not  be  if  we  were  dealing  with 
coma).  In  Chapter  IV  phenomena  of  interruption 
of  stupor  symptoms  were  detailed.  One  case  that 
was  mentioned  is  now  of  particular  importance  as 
demonstrating  that  an  appropriate  stimulus  may 
dispel  the  vacuity  of  complete  stupor  by  raising 
mental  functions  to  a  point  where  delusions  are  en- 
tertained. This  patient  retrospectively  recalled 
only  certain  periods  of  her  deepest  stupor,  occasions 
when  she  was  visited  by  her  mother.  At  these  times, 
as  she  claimed,  she  thought  she  was  to  be  electro- 
cuted and  told  her  mother  so,   adding,  "Then  it 


198  BENIGN  STUPORS 

would  drop  out  of  my  mind  again. ' '  Otherwise  her 
memory  for  this  state  was  a  complete  blank.  Here 
we  see  a  normal  stimulus  producing  not  normality 
but  something  on  the  way  towards  it,  that  is,  a 
condition  less  profound  than  the  state  out  of  which 
the  patient  was  temporarily  lifted. 

This  case  exemplifies  the  principle  of  levels  in  the 
stupor  reaction  which  we  have  found  to  be  of  great 
value  in  our  study.  These  levels  are  correlated 
with  degrees  of  regression,  as  a  review  of  the  symp- 
toms discussed  above  may  show.  In  the  first  place, 
the  dissatisfaction  with  life,  the  first  phase  of  re- 
gression, leads  to  the  quietness — the  inactivity  and 
apathy,  which  are  the  most  funadmental  symptoms 
of  the  stupor  reaction  as  a  whole.  Initiative  is  lost 
and  with  this  comes  a  tendency  for  the  acceptance 
of  other  people's  ideas.  That  is  the  probable  basis 
for  the  suggestiveness  which  we  concluded  was  a 
prominent  factor  in  catalepsy.  Indifference  and 
stolidity  may  exist  with  those  milder  degrees  of  re- 
gression which  do  not  conflict  with  one's  critical 
sense,  and  hence  may  be  present  without  any  false 
ideas.  The  next  stage  in  regression  is  that  where 
the  idea  of  death  appears.  Although  not  accepted 
placidly  by  the  subject,  its  non-acceptance  is  demon- 
strated by  the  idea  being  projected — ^by  its  appear- 
ance as  a  belief  that  the  patient  will  be  killed.  This 
notion  of  death  coming  from  without  has  again  two 
phases,  one  with  anxiety  where  normality  is  so  far 
retained  that  the  patient's  instinct  of  self-preserva- 
tion produces  fear,  and  a  second  phase  where  this  in- 


EXPLANATION  OF  THE  STUPOR  REACTION    199 

stinct  lapses  and  the  patient  so  far  accepts  the  idea 
of  being  killed  as  to  speak  of  it  with  indifference. 
The  next  step  in  regression  is  marked  by  the  spoiled- 
child  conduct,  interest  being  so  self-centered  as  to 
lead  to  autoerotic  habits  and  the  perverse  reactions 
which  we  call  negativism.  When  death  is  accepted 
but  mental  function  has  not  ceased,  the  latter  is  con- 
fined to  a  dramatization  of  death  in  physical  symp- 
toms or  to  such  speech  and  movements  as  indicate 
a  belief  that  the  patient  is  dead,  under  the  water,  or 
in  some  such  unreal  situation.  Finally,  when  all 
evidence  of  mentation  in  any  form  is  lacking,  we  see 
clinically  the  condition  which  we  know  as  deep  stu- 
por and  which  we  must  regard  psychologically  as 
the  profoundest  regression  known  to  psychopathol- 
ogy,  a  condition  almost  as  close  to  physiological  un- 
consciousness as  that  of  the  epileptic. 

Naturally  we  do  not  see  individual  cases  in  which 
all  these  stages  appear  successively,  each  sharply 
defined  from  its  predecessor.  To  expect  this  would 
be  as  reasonable  as  to  look  for  a  man  whose  beha- 
vior was  determined  wholly  by  his  most  recent  ex- 
perience. Any  psychologist  knows  that  every 
human  being  behaves  in  accordance  with  influences 
whose  history  is  recent  or  represents  the  habit  of  a 
lifetime.  At  any  given  minute  our  behavior  is  not 
simply  determined  by  the  immediate  situation,  but  is 
the  product  of  many  stages  in  our  development. 
Quite  similarly  we  should  not  expect  in  the  psychoses 
to  find  evidences  of  regression  to  a  given  period  of 
the    individuaPs    life    appearing    exclusively,    but 


200  BENIGN  STUPORS 

rather  we  should  look  for  reactions  at  any  given 
time  being  determined  preponderantly  by  the  type 
of  mentation  characteristic  for  a  given  stage  of  his 
development.  As  a  matter  of  fact,  we  see  in  psy- 
choses, particularly  in  stupor,  more  sharply  defined 
regressions  to  different  levels  than  we  ever  see  in 
normal  life. 

Our  psychological  hypothesis  would  be  incomplete 
and  probably  unsound  if  it  could  not  offer  as  valid 
explanations  for  the  atypical  features  in  our  stupor 
reactions  as  for  the  typical.  The  unusual  features 
which  one  meets  in  the  benign  stupors  are  ideas  or 
mood  reactions  occurring  apparently  as  interrup- 
tions to  the  settled  quietude  or  in  more  protracted 
mild  mood  reactions,  such  as  vague  distress,  depres- 
sion or  incomplete  manic  symptoms,  which  have  been 
described  in  the  chapter  on  affect.  The  interrup- 
tions are  easily  explained  by  the  theory  of  regres- 
sion. If  stupor  represents  a  complete  return  to  the 
state  of  nothingness,  then  the  descent  to  the  Nir- 
vana or  the  re-ascent  from  it  should  be  characterized 
by  the  type  of  thinking  with  the  appropriate  mood 
which  belongs  to  less  primitive  stages  of  develop- 
ment. A  review  of  our  material  seems  to  indicate 
that  there  is  a  definite  relationship  between  the  type 
of  onset  and  the  character  of  the  succeeding  stupor. 
For  instance,  in  the  cases  so  far  quoted  in  this  book, 
the  onsets  characterized  by  mere  worry  and  unhap- 
piness  and  gradual  withdrawal  of  interest  had  all 
of  them  typical  clinical  pictures.  On  the  other 
hand,  of  those  who  began  with  reactions  of  definite 


EXPLANATION  OF  THE  STUPOR  REACTION    201 

excitement,  anxiety  or  psychotic  depression,  there 
were  interruptions  which  looked  like  miniature 
manic-depressive  psychoses  in  all  but  one  case. 
This  would  lead  one  to  think  that  these  patients  re- 
traced their  steps  on  recovery  or  with  every  lifting 
of  the  stupor  process,  moved  slightly  upward  on 
the  same  path  on  which  they  had  traveled  in  the  first 
regression.  The  case  of  Charlotte  W.  (Case  12), 
which  is  fully  discussed  in  the  chapter  on  Ideational 
Content,  offers  excellent  examples  of  these  prin- 
ciples. 

The  next  atypical  feature  is  the  phenomenon  of 
reduction  or  dissociation  of  affect,  the  frequency  of 
which  is  mentioned  in  Chapter  V.  As  the  law  of  stu- 
por is  apathy,  normal  emotions  should  be  reduced 
to  indifference  and  no  abnormal  moods,  such  as  ela- 
tion, anxiety  or  depression,  should  occur.  What 
often  happens  is  that  these  psychotic  affects  ap- 
pear but  incompletely,  often  in  dissociated  mani- 
festations. This  looks  like  a  combination  of  two 
psychotic  tendencies,  the  stupor  reduction  process 
which  inhibits  emotional  response  and  the  tendency 
to  develop  abnormal  affects  which  characterize 
other  manic-depressive  psychoses.  There  is  no 
general  psychological  law  which  makes  this  view  un- 
likely. One  cannot  be  anxious  and  happy  at  the 
same  instant,  although  one  can  alternate  in  his  feel- 
ings ;  but  one  can  fail  to  react  adequately  to  a  given 
stimulus  when  inhibited  by  general  indifference.  In 
fact  it  is  because  apathy  is,  properly  speaking,  not 


202  BENIGN  STUPORS 

a  mood  but  an  absence  of  it,  that  it  can  be  combined 
with  a  true  affect.  It  is  possible,  therefore,  to  have 
a  combination  of  stupor  and  another  manic-depres- 
sive reaction,  while  the  others  cannot  combine  but 
only  alternate.^ 

Finally  we  must  discuss  the  psychological  mean- 
ing of  cases,  such  as  those  described  in  Chap- 
ter VIII,  where  we  concluded  that  there  were 
psychoses  resembling  stupors  superficially.  It 
seemed  likely  that  these  patients  were  absorbed  in 
their  own  thoughts,  rather  than  being  in  a  condition 
of  mental  vacuity.  It  is  not  difficult  to  explain  the 
objective  resemblance.  All  evidence  of  emotion 
(apart  from  subjective  feeling  tone  which  the  sub- 
ject may  or  may  not  report)  is  an  expression  of  con- 
tact with  the  outer  world.  There  must  be  externali- 
zation  of  attention  to  environment  before  a  mood 
becomes  evident.  A  moment's  reflection  will  show 
this  to  be  true,  for  no  further  proof  is  needed  than 
the  phenomena  of  dreaming.  The  attention  being 
given  wholly  to  fantasies,  the  subject  lies  motionless, 
mute  and  placid,  although  passing  through  varied 
autistic  experiences.  Only  when  the  dream  becomes 
too  vivid,  disturbs  sleep  and  re-directs  attention  to 
the  environment — only  then  is  emotion  objectively 

^  The  reader  will  note  that  this  view  is  opposed  to  that  of 
Kraepelin,  who  has  written  largely  on  so-called  "mixed  conditions" 
in  manic-depressive  insanity.  We  believe  that  careful  clinical  stud- 
ies confirm  our  opinion  and  that  his  classification  is  based  on  less 
thorough  observation  and  analysis.  This  subject  will  be  discussed 
at  greater  length  in  a  forthcoming  book  on  "The  Psychology  of 
Morbid  and  Normal  Emotions,"  by  Dr.  MacCurdy. 


EXPLANATION  OF  THE  STUPOR  REACTION    203 

betrayed.  There  is  an  appearance  of  apathy  and 
mental  vacuity  which  the  dreamer  can  soon  declare 
to  be  false.  He  was  feeling  and  thinking  intensely. 
In  any  condition,  therefore,  such  as  that  of  perplex- 
ity or  of  an  absorbed  manic  state,  the  patient  may 
be  objectively  in  the  same  condition  as  a  typical 
stupor.  The  histories  of  the  two  psychoses  differ- 
entiate the  two  reactions  which  may  be  indistin- 
guishable at  one  interview.  The  keynote  of  one  re- 
action is  indifference,  while  that  of  absorption  is 
distraction,  a.  perversion  of  attention  to  an  inner, 
unreal  world. 

In  summary  we  may  recapitulate  our  hypotheses. 
Stupor  represents,  psychologically  speaking,  the 
simplest  and  completest  regression.  Adaptation  to 
the  actual  environment  being  abandoned,  attention 
reverts  to  earlier  interests,  giving  symptoms  of 
other  manic-depressive  reactions  in  the  onset  or 
interruptions,  and  finally  dwindles  to  complete  in- 
difference. The  disappearance  of  affective  impulse 
leads  to  objective  apathy  and  inactivity,  while  the 
intellectual  functions  fail  for  lack  of  emotional 
power  to  keep  them  going.  The  complicated  mental 
machine  lies  idle  for  lack  of  steam  or  electricity. 
The  typical  ideational  content  and  many  of  the 
symptoms  of  stupor  are  to  be  explained  as  expres- 
sions of  death,  for  a  regression  to  a  Mrvana-like 
state  can  be  most  easily  formulated  in  such  a  de- 
lusion. Other  clinical  conditions  may  temporarily 
and  superficially  resemble  stupor  on  account  of  the 


204  BENIGN  STUPORS 

attention  being  misdirected  and  applied  to  unpro- 
ductive imaginations.  To  employ  our  metaphor 
again,  in  these  false  stupors  the  current  is  switched 
to  another,  invisible  machine  but  not  cut  off  as  in 
true  stupor. 


CHAPTER  XI 
MALIGNANT  STUPORS 

As  we  have  seen,  the  benign  stupors  are  character- 
ized by  apathy,  inactivity,  mutism,  a  thinking  disor- 
der, catalepsy  and  negativism.  All  these  symptoms 
are  also  found  in  the  stupors  occurring  in  dementia 
prsBcox.  In  fact  this  symptom  complex  has  usually 
been  regarded  as  occurring  only  in  a  malignant  set- 
ting. There  can  be  no  question  about  the  resem- 
blance of  benign  to  dementia  praecox  stupors.  Even 
such  symptoms  as  poverty  and  dissociation  of  atf  ect, 
usually  regarded  as  pathognomonic  of  dementia 
praecox,  have  been  described  in  the  foregoing  chap- 
ters. Either  recovery  in  our  cases  was  accidental 
or  there  is  a  distinct  clinical  group  with  a  good  prog- 
nosis. If  the  latter  be  true,  the  symptoms  must 
follow  definite  laws ;  if  they  did  not,  we  would  have 
to  abandon  our  principles  of  psychiatric  classifica- 
tion. Naturally,  then,  we  seek  to  find  the  differences 
between  the  cases  that  recover  and  those  that  do  not. 
There  is  never  any  difficulty  in  diagnosis  where  a 
stupor  appears  as  an  incident  in  the  course  of  a  rec- 
ognized case  of  catatonic  dementia  praecox.  We 
shall  therefore  consider  only  such  clinical  pictures  as 
resemble  those  described  in  this  book,  in  that  the 

205 


206  BENIGN  STUPORS 

symptoms  on  admission  to  a  hospital  or  shortly 
after  are  those  of  stupor.  It  should  be  our  ambi- 
tion to  make  a  positive  diagnosis  before  failure  to 
recover  in  a  reasonable  time  leads  to  a  conclusion 
of  chronicity. 

It  is  probably  safe  to  assume,  on  the  basis  of  as 
large  a  series  as  ours,  that  the  symptoms  of  stupor 
per  se  imply  no  bad  prognosis.  Further,  it  has  been 
noted  that  a  relatively  pure  type  of  reaction  is  seen, 
the  symptoms  appearing  with  tolerable  consistency. 
In  analyzing  the  histories  of  dementia  prsecox  pa- 
tients, therefore,  one  looks  for  inconsistencies 
among,  or  additions  to,  the  stupor  symptoms.  We 
may  say  at  the  outset  that  we  have  been  able  to  find 
no  case  of  malignant  stupor  that  showed  what  we 
regard  as  a  typical  benign  stupor  reaction,  and  it  is 
questionable  whether  partial  stupor  as  we  have  de- 
scribed it,  ever  occurs  with  a  bad  prognosis.  Usu- 
ally the  discrepant  symptoms  in  the  dementia  prae- 
cox  cases  are  sufficiently  marked  to  enable  one  to 
make  a  positive  diagnosis  quite  soon  after  the  case 
comes  under  observation. 

The  law  of  benign  stupor  is  a  limitation  of  energy, 
emotion  and  ideational  content.  In  dementia  prae- 
cox  we  have  a  re-direction  of  attention  and  interest 
to  primitive  fantastic  thoughts  and  a  consequent 
perversion  of  energy  and  emotion.  In  many  malig- 
nant stupors  one  can  detect  evidence  of  this  second 
type  of  reaction  in  symptoms  that  are  anomalous 
for  stupor.  For  instance,  one  meets  with  frequent 
silly  and  inexplicable  giggling.     Then,  too,  smiling, 


MALIGNANT  STUPORS  207 

tears  or  outbursts  of  rage,  the  occasions  for  which 
are  not  manifest,  are  much  more  frequent  than  in 
typical  stupor.  Similarly,  delusional  ideas  (not 
concerned  with  death  at  all)  may  appear  or  the  pa- 
tient may  indulge  in  speech  that  is  quite  scattered, 
not  merely  fragmentary.  Two  cases  may  be  cited 
briefly  to  illustrate  these  dementia  prsecox  symp- 
toms superadded  to  those  of  stupor. 

Case  20.— Winifred  O'M.  Age :  19.  Single.  Admitted  to  the 
Psychiatric  Institute  May  6,  1911. 

F.  H.  The  occurrence  of  other  nervous  or  mental  disease  in 
the  family  was  denied. 

P.  H.  The  patient  seems  to  have  been  rather  shy  and  goody- 
goody  in  disposition.  According  to  her  mother  this  seclusiveness 
did  not  begin  to  be  markedly  noticeable  until  the  winter  before 
her  psychosis,  when  there  was  some  trouble  about  getting  work. 
She  had  previously  been  to  a  business  school.  Then  she  held  a 
position  as  stenographer  temporarily.  When  this  job  was  over 
she  had  a  number  of  positions  that  did  not  last  long  and  was 
once  idle  for  two  months.  In  February  (three  months  before 
admission)  her  father  was  out  of  work,  which  added  to  her  worry. 

Onset  of  Psychosis:  Nine  days  before  admission  a  young  man 
died  in  the  house  where  they  lived.  The  next  day  her  mother 
insisted  on  the  patient  and  her  sister  going  to  the  funeral.  On 
coming  home  the  patient  complained  of  being  afraid  and  having 
a  funny  feeling.  She  woke  up  at  2 :30  that  night  and  lit  all  the 
gas,  for  which  she  could  give  no  explanation.  The  day  following, 
or  a  week  before  admission,  she  was  slow,  confused,  could  not  get 
her  clothes  together.  The  next  day  she  was  restless  and  worried, 
giving  a  superficial  explanation  for  the  latter.  She  played  the 
piano  a  great  deal.  The  following  day  she  was  fidgety  and  cried. 
At  4  p.  m.  she  was  put  to  bed  and  appeared  to  fall  asleep.  At 
midnight  when  a  priest  called  she  said  to  him  privately  that  she 
was  all  over  the  world,  that  she  went  to  the  12th  floor  of  the 
Metropolitan  Building,  that  she  sat  down  and  took  the  man's 
money,  $7,   and  came  right   away.     She   recognized  the  priest. 


208  BENIGN  STUPORS 

Three  days  before  admission  she  wanted  to  stay  in  bed,  kept  her 
eyes  closed.  When  spoken  to  she  would  smile  but  did  not  open 
her  eyes.  She  did  not  pass  her  urine  all  day.  Her  mother  then 
gave  her  some  medicine  which  the  doctor  had  left.  The  patient 
immediately  had  a  peculiar  attack  in  which  she  heaved  her  breast, 
drew  her  head  back,  clenched  her  fists  and  worked  her  feet.  Saliva 
escaped  from  the  side  of  her  mouth.  This  attack  lasted  some 
three  to  five  minutes. 

Her  mother  then  called  an  ambulance  and  she  was  taken  to  the 
Observation  Pavilion.  She  thought  that  the  ambulance  doctor 
was  an  uncle,  a  soldier  in  the  Philippines,  of  whom  she  was  very 
fond.  There  she  remained  in  bed,  with  all  her  muscles  relaxed, 
her  mouth  constantly  open,  saying  nothing  and  indeed  resisting 
efforts  which  were  made  to  get  her  to  open  her  eyes. 

Under  Observation :  She  sat  or  lay  down  with  her  eyes  closed 
and  usually  limp,  although  occasionally  resistive.  There  was  prac- 
tically no  reaction  to  pin  pricks.  Sometimes  she  opened  her 
mouth  as  if  to  speak  but  rarely  did  so  except  in  a  very  low  tone 
and  after  repeated  questioning.  Her  answers  were  rarely  rele- 
vant. To  the  usual  orientation  questions  she  gave  no  answers 
that  would  indicate  that  she  knew  where  she  was.  Sometimes  she 
said  "Jimmy"  when  asked  her  name,  and  replied  to  another 
question,  "Jimmy  big  smile  on."  Once  she  said,  "I  don^t  know 
myself — what  I  am  talking  for — ^what  I  am  doing."  In  general 
her  speech  seemed  to  indicate  that  her  thought  was  directed 
entirely  inward  and  that  she  paid  no  attention  whatever  to  the 
questions.  In  most  benign  cases  such  a  condition  is  accompanied 
by  perplexity  or  a  dreamy,  dazed  expression.  This  the  patient 
had  not.  On  the  other  hand,  she  was  sometimes  definitely  scat- 
tered. For  example,  when  asked.  How  do  you  feel?  she  replied, 
"Large  all  name."  Again  to  the  command,  Tell  me  your  trouble, 
her  answer  was,  "I  couldn't  tell  my  mother  last  night  and  I  can't 
tell  her  this  night  and  I  can't  tell  my  proud."  She  referred  in 
a  fragmentary  way  to  being  crazy  and  to  having  been  dead.  She 
admitted  hearing  voices  but  may  not  have  understood  the  question. 

A  week  after  admission,  when  visited  by  her  mother,  the  latter 
asked  her  to  kiss  her.  The  patient  opened  her  mouth  widely  and 
put  out  her  tongue.  This  is  a  type  of  response  which  we  have 
never  seen  in  our  benign  cases. 


MALIGNANT  STUPORS  209 

Two  days  later  repeated  questioning  made  it  evident  that  the 
patient  knew  more  about  her  environment  than  would  be  expected, 
judging  from  her  other  symptoms.  She  gave  the  month  correctly 
knew  that  she  was  in  a  hospital  and  told  of  having  recently  been 
visited  by  her  father.  At  the  same  interview  she  spoke  of  mas- 
turbation, of  wanting  to  marry  her  uncle,  and  of  having  been  in 
bed  with  her  father.  The  last  she  referred  to  as  a  "fall."  Such 
frank  incest  ideas  are  never  found  in  benign  psychosis  in  our 
experience.  Other  dementia  praecox  ideas  appeared  quite  soon, 
for  within  three  days,  when  she  was  talking  slightly  more  freely, 
she  spoke  of  having  often  imagined  she  was  having  sexual  expe- 
riences as  a  result  of  the  influence  of  a  man  who  lived  upstairs, 
and  that  even  when  sitting  with  her  family  at  the  table  she  felt 
sexual  sensations. 

Her  condition  then  remained  essentially  the  same  for  some 
time.  Then  about  six  weeks  after  admission  she  became  somewhat 
less  resistive,  was  frequently  seen  sitting  up  in  bed,  moving  her 
lips  considerably  (without  speech)  and  regarding  the  surround- 
ings with  a  bright  interested  expression  and  occasionally  smiles. 
About  this  time  she  began  exposing  herself  and  chewing  her 
finger  nails. 

Four  months  after  admission  she  was  noted  as  being  very 
resistive  and  negativistic,  allowing  saliva  to  accumulate  in  her 
mouth  and  making  no  attempt  to  keep  the  flies  off  her.  At  the 
same  time  she  would  keep  in  her  mouth  food  that  had  been  put 
there  without  chewing  it. 

Two  months  later  she  seemed  to  laugh  occasionally  when  other 
patients  did  so,  but  at  the  same  time  she  showed  a  cataleptic 
tendency  and  was  quite  mute. 

Six  months  after  admission  she  began  to  feed  herself  but  rather 
sloppily.  When  one  would  speak  to  her,  she  would  occasionally 
smile,  but  if  shaken  she  would  weep  silently.  About  this  time  she 
began  to  do  a  little  work  in  the  ward,  pushing  a  floor  polisher. 

For  the  next  couple  of  months  her  condition  was  about  the 
same.  She  would  stand  around  the  ward,  doing  a  little  work  if 
urged,  might  even  dance  if  forced  to.  She  was  consistently  mute. 
She  was  dirty  but  often  decorated  herself.  Rarely  she  was 
assaultive. 

Then  ten  months  after  admission  she  one  day  suddenly  became 


210  BENIGN  STUPORS 

talkative,  distractible  and  emotional,  laughing  and  crying.  There 
was  with  this,  however,  no  open  elation.  Her  talk  was  obscene, 
at  times  flighty,  at  times  definitely  scattered.  All  her  habits  were 
filthy. 

This  pseudomanic  episode  lasted  for  a  couple  of  months,  and 
then  she  settled  down  to  a  fairly  consistent  deterioration  with 
indifference,  silly  laughter,  occasional  assaultiveness,  destructive- 
ness  and  untidiness. 

Nearly  two  years  after  admission  she  had  another  period  of 
excitement  lasting  about  a  couple  of  months.  Shortly  after  this 
she  began  to  fail  physically,  and  in  November,  1913,  two  years 
and  five  months  after  her  admission,  she  died  of  pulmonary 
tuberculosis. 

In  summary,  then,  we  see  that  this  patient  exhib- 
ited symptoms  of  dementia  prsecox  from  the  outset 
of  her  stupor,  with  scattering,  genital  sensations 
and  incest  ideas.  The  stupor  symptoms  gradually 
gave  way  to  the  typical  indifference,  negativism,  ob- 
scenity, filthiness  and  inexplicable  conduct  of 
dementia  prsecox.  At  the  beginning,  however,  the 
condition  was  superficially  similar  to  that  of  a  be- 
nign stupor,  it  being  only  on  careful  observation 
that  other  symptoms  were  noted. 

Case  21. — Rose  S.  Age:  23.  Admitted  to  the  Psychiatric 
Institute  April  5,  1905. 

F.  H.  The  mother  was  living,  the  father  dead.  Otherwise  no 
pertinent  information  was  secured. 

P.  H.  The  patient  was  said  always  to  have  been  somewhat 
seclusive,  mingling  little  with  other  people;  this  tendency  was  so 
strong  that  she  would  leave  the  room  when  visitors  came.  She 
always  slept  a  great  deal.  It  was  stated  that  she  was  able  to  do 
heavy  housework  quite  well,  but  never  learned  cooking. 

At  16  she  hired  out  as  a  servant  for  a  year  and  a  half,  and  then 
did  laundry  work.  When  18  she  had  an  illegitimate  child  by  a 
co-worker. 


MALIGNANT  STUPOKS  211 

History  of  Psychosis:  About  a  year  before  admission  the 
patient's  sister  was  burned  to  death.  When  the  patient  heard  of 
this  she  said  that  something  had  come  up  in  her  throat.  Hence- 
forth she  often  complained  of  a  lump  in  her  throat,  and  often  bit 
her  nails.  Two  months  before  admission  she  suddenly  left  the 
laundry,  again  spoke  of  the  lump  in  her  throat,  and  claimed  to 
have  seen  the  dead  sister.  Two  weeks  later  when  the  family  had 
an  anniversary  mass  for  the  sister  the  patient  appeared  sad,  but 
the  following  day  laughed,  said  she  had  seen  her  "sister  beckoning 
her  to  come."  She  also  thought  she  saw  her  picture  "and  Heaven 
was  behind  it."  She  also  talked  of  "dead  relatives  and  friends." 
A  reaction  of  levity  in  connection  with  a  sister's  death  is  highly 
suggestive  of  a  malignant  psychosis. 

Two  weeks  before  admission  her  mother  found  her  in  a  stupor, 
immovable,  with  her  eyes  closed.  In  24  hours  she  woke  up,  began 
to  sing  "Rest  for  the  Weary,"  prayed,  then  was  stuporous  again 
for  six  hours.  When  she  came  out  of  this,  she  said  she  was 
"going  to  die,"  God  had  told  her  so  and  talked  of  her  own  funeral 
arrangements.  She  again  went  into-  a  stupor,  in  which  she  was 
sent  to  the  Observation  Pavilion. 

At  the  Observation  Pavilion  she  was  described  as  happy,  laugh- 
ing, singing,  saying  she  felt  happy,  but  adding,  "I  like  to  be  sad 
too,  I  am  going  to  Heaven  Easter  Sunday."  She  claimed  that 
her  sister  frequently  stood  in  front  of  her,  and  that  she  knew  she 
wanted  her  to  go  with  her. 

Under  Observation :  For  about  three  weeks  the  patient  showed 
a  variable  stupor.  She  would  lie  with  a  mask-like  face  inacces- 
sible, cataleptic,  drooling  salivia,  often  with  her  mouth  open. 
When  taken  up,  she  was  usually  perfectly  flaccid,  but  once  she 
let  herself  slide  on  the  floor  after  she  had  stood  immobile  at  the 
window.  Sometimes  there  was  marked  resistance  to  passive 
motions,  especially  when  attempts  were  made  to  open  her  mouth 
or  eyes,  or  on  one  occasion  when  the  examiner  tried  to  open  her 
hand  in  which  she  held  her  handkerchief.  Yet  when  one  persisted 
in  urging  her  to  respond  there  frequently  could  be  elicited  more 
or  less  marked  reactions.  Thus  repeatedly  she  could  be  made  to 
obey  some  commands,  as  showing  the  tongue,  etc.,  even  when  she 
would  not  answer.  Once  when  her  eyes  were  opened,  tears  rolled 
down   her  cheeks — again,  she  usually  reacted  to  pin  pricks  by 


212  BENIGN  STUPORS 

slight  flushing,  once  she  said,  "Stop !  it  hurts."  Again,  she  said, 
"Leave  me  alone,  I  want  to  sleep." 

So  far  the  description  of  this  reaction  is  that  of  a  benign 
stupor.  There  were,  however,  other  symptoms.  In  the  first  place, 
she  could  sometimes  be  made  to  open  her  eyes  and  write,  although 
she  would  not  speak.  In  spite  of  the  penmanship  being  careless, 
there  were  no  mistakes.  This  exhibition  of  an  unhabitual  and 
more  difficult  intellectual  effort  when  the  patient  was  mute  is 
suggestive  of  an  inconsistency.  So  was  her  habit  of  sometimes 
singing  a  hymn,  "Rest  for  the  Weary,"  when  no  other  sign  of 
mental  life  was  given.  But,  more  important  than  these,  she  could 
not  infrequently  be  induced  to  answer  questions  and  at  such  times 
she  spoke  promptly  and  with  natural  affective  response. 

A  number  of  her  replies  were  of  the  type  to  be  expected  in  a 
benign  stupor.  In  the  first  place,  she  spoke  of  her  condition  as 
"going  off  to  sleep"  and  also  as  "death,"  "I  was  dead  all  day." 
"I  died  three  times  yesterday,"  or  she  merely  described  it  by 
saying  "I  go  off  into  states  when  I  lie  with  my  mouth  open  and 
eyes  closed,  and  cannot  speak  or  open  my  eyes."  When  asked 
how  she  got  into  this  condition,  she  said  "My  sister  died  and  I 
think  it  was  on  my  mind."  Again  she  said  she  became  sad  at 
the  anniversary  mass  of  the  sister  and  had  been  sad  ever  since. 
On  the  other  hand,  she  also  stated  that  when  she  came  home 
from  the  mass  she  first  was  silly  and  danced.  Spontaneously  she 
spoke  of  having  frequently  had  visions  of  her  dead  sister;  once 
she  saw  her  with  wings.  In  explanation  of  her  singing  "Rest  for 
the  Weary,"  she  said  it  was  the  hymn  sung  at  her  father's 
funeral.  An  anomalous  feature  had  to  do  with  her  description 
of  her  feelings.  She  claimed  to  have  no  memory  of  her  stupor 
periods  and  yet  said  of  them:  "I  feel  peaceful-like,"  or  "I  feel 
awfully  happy  and  sad  together,"  or  "I  am  sad  and  contented — 
I  like  it  that  way." 

A  striking  symptom  was  that,  when  a  sensory  examination  was 
made  during  the  first  few  days  during  one  of  the  periods  when 
she  responded  well,  she  showed  glove  and  stocking  anesthesia, 
also  anesthesia  of  neck  and  left  breast. 

But  in  addition  to  the  above  statements  the  patient  also  began 
to  make  others  of  a  definite  dementia  praecox  type.  About  ten 
days  after  admission  she  said,  "What  any  one  says  goes  right 


MALIGNANT  STUPORS  213 

through  my  brain,"  or  she  talked  of  being  hypnotized.  "The 
typewriting  machine  turned  my  eyes — three  or  four  girls  turned 
my  eyes — they  look  at  me  and  get  their  chance,  their  left  eye — 
turning  me  into  images.  I  want  to  be  the  way  I  was  born — turn 
my  body!  look  how  their  bodies  are  turned  before  they  die,"  or 
"Take  it  if  you  get  it — he  got  the  name  out — I  was  over  there  to 
death — himself  to  death — of,  you  know — you  played  out — ^she  is 
played  out."  .  .  .  This  while  she  snickered  between  the  sentences. 
As  early  as  four  weeks  after  admission  she  had  begun  to  giggle 
or  laugh,  often  in  an  empty  fashion,  and  a  transition  from  the 
more  constrained  stuporous  state,  with  interruptions  of  laughter, 
to  an  indifferent  silly,  muttering  to  herself  was  gradual. 

In  1909  she  was  described  as  not  talking,  standing  around, 
showing  no  interest  in  anything,  muttering.  The  only  response 
obtained  was  "I  don't  know."  In  December,  1911,  she  was  trans- 
ferred to  another  hospital  as  a  case  of  deteriorated  dementia 
preeeox. 

To  Recapitulate :  We  have  here  a  young  woman 
who  for  a  year  had  indefinite  mental  symptoms  and 
suddenly  developed  a  stupor.  This  was  atypical  in 
that  she  sang  and  wrote  when  otherwise  apparently 
deeply  stuporous.  When  persuaded  to  talk,  her  ut- 
terances, even  as  early  as  ten  days  after  admission, 
were  of  a  malignant  type  and  with  such  statements 
she  giggled.  This  last  is  apparently  a  highly  im- 
portant sign.  Quite  frequently  in  our  cases  the  first 
signal  of  a  dementia  praecox  reaction  has  been  gig- 
gling in  a  setting  of  what  was  apparently  a  typical 
benign  stupor. 

As  has  frequently  been  stated,  symptoms  of  be- 
nign stupor  are  closely  interrelated.  Consequently 
the  reaction  is,  when  benign,  a  consistent  one.  We 
do  not  find  free  speech  with  profound  apathy  and  in- 


214  BENIGN  STUPORS 

activity,  nor  do  we  expect  to  meet  with  unimpaired 
intellectual  functions  when  other  evidences  of  deep 
stupor  are  present.  The  inconsistency  of  mental 
operations  which  characterize  dementia  prsecox, 
however — the  '' splitting' '  tendency  which  Bleuler 
has  emphasized  in  his  term  "schizophrenia" — ^is 
just  that  added  factor  which  may  produce  dispro- 
portionate developments  of  the  various  stupor 
symptoms  in  the  dementia  prsecox  type  of  that  re- 
action. Examples  of  this  have  been  given  in  the  two 
cases  just  quoted.  The  history  of  the  following  pa- 
tient shows  this  tendency  more  prominently. 

Case  22. — Nellie  H.  Age:  20.  Admitted  to  the  Psychiatric 
Institute  June  11,  1907. 

F.  H.  The  father  had  repeated  depressions;  he  died  of  typhus 
fever.     The  mother  was  living. 

P.  H.  The  brother  of  the  patient  stated  that  she  was  like  other 
girls,  and  very  good  at  school.  At  16  she  became  quieter,  less 
energetic.  She  came  to  America  at  17.  After  arriving  here  she 
has  seemed  low  spirited,  cranky  and  faultfinding.  She  often 
complained  of  indefinite  stomach  trouble  and  headaches;  when 
at  home  she  often  had  a  cloth  around  her  head.  The  informant 
recalled  that  she  said,  "I  wish  I  could  get  sick  for  a  long  time 
and  get  either  cured  or  die."  However,  she  worked.  For  one  and 
a  half  years  prior  to  admission  her  "crankiness"  is  said  to  have 
become  much  worse.  She  complained  continually  of  being  tired; 
quarreled  much  with  her  mother;  said  she  did  not  have  enough 
to  eat.  It  is  also  stated  that  she  was  constantly  afraid  of  losing 
her  job. 

History  of  Psychosis:  For  six  months  before  admission  she 
said  frequently  that  her  boss  was  giving  her  hints  that  he  liked 
her.  (She  did  not  know  him  socially  at  all.)  Six  days  before 
admission  she  came  home,  saying  the  boss  had  told  her  he  had 
no  more  work  for  her.  Nevertheless,  she  went  back  next  day  and 
was  again  sent  home.    At  home  she  sat  gazing.    Next  day  again 


MALIGNANT  STUPORS  215 

wanted  to  go  and  see  the  boss,  but  was  prevented.  At  times  she 
tried  to  get  out  of  the  window;  again  sat  gazing,  repeating  to 
herself  "Always  be  true."  She  said  she  was  in  love  with  the 
boss.  When  the  doctor  gave  her  medicine  she  thought  it  was 
poison.  Finally  she  began  to  be  talkative  and  elated.  At  the 
Observation  Pavilion  she  became  very  quiet. 

Under  Observation:  She  lay  in  bed  indifferent,  not  eating, 
unless  spoon-fed,  when  she  would  swallow.  She  soiled  herself. 
She  answered  no  questions  as  a  rule,  and  only  on  one  occasion, 
when  urged  considerably,  said  in  answer  to  questions  that  this 
was  a  hospital,  so  that  she  evidently  had  more  grasp  on  the  nature 
of  her  environment  than  her  behavior  indicated.  To  her  brother 
who  called  on  her  during  the  first  ten  days  she  said  she  could  not 
find  her  lover  here  (an  idea  inconsistent  with  the  benign  stupor 
picture). 

Then  she  became  more  markedly  stuporous,  drooling  saliva, 
very  stiff,  often  lying  with  head  half  raised,  gazing  stolidly,  never 
answering,  soiling.  Later,  after  a  month,  this  was  less  con- 
sistent. She  now  and  then  went  to  the  closet,  sometimes  she 
smiled,  ate  some  fruit  brought  to  her,  spoke  a  little.  Repeatedly 
when  people  came  she  clung  to  them,  wanted  to  go  home,  again 
was  seen  to  weep  silently.  On  another  occasion  she  suddenly 
threw  the  dishes  on  the  floor  with  an  angry  mood,  without  there 
being  any  obvious  provocation.  Again  she  got  quite  angry  when 
urged  to  eat  her  breakfast,  and  on  that  occasion  pulled  out  some 
of  her  own  hair.  Usually  she  had  to  be  fed,  was  stiff,  sitting 
with  closed  fists,  not  reacting  as  a  rule  in  any  other  way,  wholly 
inaccessible  and  has  been  that  way  for  years.  The  stupor  merged 
into  a  catatonic  state  merely  by  the  development  of  the  in- 
consistency in  her  affective  reactions. 

We  see  then  that  inconsistencies  among  the  stupor 
symptoms  themselves  and  the  intrusion  of  definitely 
dementia  praecox  symptoms  differentiate  the  malig- 
nant from  the  benign  reactions.  As  a  matter  of 
fact,  we  find,  as  a  rule,  that  careful  examination  of 
the  onset  reveals  further  atypical  features,  sugges- 


216  BENIGN  STUPORS 

tions  or  definite  evidences  of  a  dementia  prsecox  re- 
action before  the  stupor  itself  appears.  One  com- 
mon occurrence  is  a  slow  deterioration  of  character 
and  energy  that  proceeds  for  months  or  years  before 
flagrantly  psychotic  symptoms  appear. 

Then  when  delusions  or  hallucinations  are  eventu-- 
ally  spoken  of  by  the  patient,  an  appropriate  or 
adequate  reaction  is  lacking.     In  a  benign  psychosis 
false  ideas  do  not  appear  with  an  equable  mood 
unless  the  stupor  reaction  has  already  begun. 

More  important  than  this,  although  in  benign  stu- 
pors there  may  be  a  reduction  or  an  insufficient  af- 
fect, it  is  never  inappropriate.  This  pathognomonic 
symptom  of  dementia  prsecox  frequently  occurs  in 
the  onset  to  malignant  stupors.  In  fact  we  often 
find  in  reviewing  such  cases  that  a  plain  dementia 
prsecox  reaction  has  been  in  evidence,  that  a  diag- 
nosis has  not  been  made  simply  because  the  stupor 
picture  blotted  out  this  earlier  psychosis  before  an 
opinion  was  formed.  Frequently  these  early  symp- 
toms are  reported  in  the  anamnesis  and  not  actually 
observed  by  the  physician. 

Three  cases  may  be  cited  as  examples  of  dementia 
prsecox  onsets.  It  will  be  noted  that  the  ensuing 
stupors  were,  like  those  already  quoted,  atypical. 

Case  23. — Catherine  H.  Age:  21.  Admitted  to  the  Psychiatric 
Institute  October  10,  1904. 

F.  H.  The  mother's  brother  had  two  attacks  of  delirium 
tremens.  The  mother  died  when  the  patient  was  eleven  years  old; 
she  is  said  to  have  been  normal.    The  father  was  living. 

P.  H.     The  patient  was  always  a  nervous  child,  had  very  bad 


MALIGNANT  STUPORS  217 

dreams,  but  she  was  smart  at  school  up  to  ten  or  eleven,  and 
played  with  other  girls.  Then  she  began  to  work  less  well,  got 
thin,  more  nervous,  complained  of  headaches.  It  was  about  that 
time  that  her  mother  died.  (The  reaction  to  the  death  was  said 
not  to  have  been  different  from  that  of  her  sister.)  She  was 
kept  at  home  and  was  quiet.  .  .  .  "You  could  see  something  was 
working  on  her."  She  began  to  menstruate  at  14,  and  it  was 
claimed  that  she  then  wakened  up  a  little.  It  was  further  stated 
that  she  was  always  "stuck  up"  about  her  clothes. 

At  16  she  went  to  work  in  a  factory,  but  her  sister  thought 
the  work  was  too  much  for  her,  so  she  was  taken  home.  There- 
after she  lived  alone  with  her  father,  doing  his  housework,  her 
sister  having  married  about  that  time.  At  17  her  hair  began 
to  come  out  excessively,  so  that  she  had  to  cut  it,  and  when  it 
grew  again  it  was  gray.  She  became  very  sensitive  about  this, 
even  refused  to  take  positions  because  she  thought  people  would 
remark  about  it. 

For  two  years  before  admission  she  evidently  was  different. 
Although  she  did  her  father's  housework  well  enough,  she  turned 
against  her  sister  and  refused  to  speak  to  her  because,  she  alleged, 
the  sister  had  not  come  to  help  her  in  her  housework.  Another 
pronounced  manifestation  during  that  time  was  her  frequent  talk 
about  her  bowels.  She  complained  of  constipation,  creepy, 
crawling  sensations  in  the  stomach  which  she  thought  was  a 
"tapeworm."  She  got  pamphlets  and  took  patent  medicines.  She 
was  taken  to  a  physician  nine  months  before  admission,  who 
operated  on  her  for  piles.  While  still  in  the  hospital  she  asked 
her  father  to  take  her  home  to  die  (although  there  was  no  reason 
for  such  a  request).  Again  she  said  the  gauze  had  been  left  in 
the  rectum  too  long  and  that  the  rectum  was  full  of  wind.  Later 
she  said  the  rectum  was  closing  up.  After  this,  the  sister  stated, 
she  was  extremely  nervous  if  she  passed  a  day  without  a  move- 
ment of  the  bowels.  She  was  quiet  henceforth,  went  out  less  and 
said  little,  claiming  it  was  better  for  her  head  if  she  said  little. 
She  often  sat,  head  in  hand,  in  the  hall.  All  through  the  summer 
she  frequently  remarked,  "I  am  a  good  girl."  Four  months  before 
admission  during  a  period  of  five  weeks  she  would  let  her  bowels 
move  when  standing  up.  This  was  relieved  by  enemas.  The 
father  states  that  she  was  cranky  to  him,  that  sometimes  when 


218  BENIGN  STUPORS 

he  merely  asked  a  question  she  would  say,  "You  hurt  my  feelings," 
and  once,  "You  break  my  heart."  Occasionally  she  seemed  to 
worry  about  the  money  spent  for  her  on  doctors  and  medicine. 

About  two  months  before  admission  she  said  everybody  was 
looking  at  her.  Ten  days  before  admission  she  said,  "I  have  been 
sick  all  this  time  and  thought  I  was  going  to  die.  Now  I  think 
Tom  (her  brother)  is  going  to  die."  She  became  fearful  of 
being  left  alone.  Finally  she  went  to  the  priest,  who  told  her  to 
go  home.  Then  she  prayed,  leaving  the  candles  burning  in  the 
room.  That  night  she  was  found  kneeling  before  a  church  in  her 
nightgown.  Again  she  threw  a  lot  of  articles  into  the  yard,  saying 
a  curse  had  been  put  on  her  by  her  father,  and  she  did  not  wish 
to  give  him  anything.  When  she  was  taken  to  the  Observation 
Pavilion  she  said,  "I  am  a  good  girl — ^my  mother  is  dead — it  is  all 
my  father's  fault." 

At  the  Observation  Pavilion  she  put  her  arm  under  a  hot 
water  faucet  "to  save  the  world,"  prayed  and  laughed — again 
sank  back  and  appeared  as  if  asleep.  She  said,  "I  hear  angels 
telling  me  how  to  pray  when  I  lose  my  thoughts — sisters  and  nuns 
are  all  around  me  here,  to  save  and  purify  the  world  now  and 
forever,  and  at  the  hour  of  our  death." 

Under  Observation:  On  admission  the  patient  kept  her  eyes 
closed,  sang  hymns  in  measured  tones,  or  prayed,  or  showed  a 
certain  ecstasy  in  her  face  while  her  lips  quivered  and  tears  ran 
down  her  cheeks.  On  the  whole,  she  answered  few  questions. 
When  asked  how  she  felt,  she  said  she  was  happy.  (Why  do 
you  cry?J  "I  was  crying  when  I  asked  God  to  save  souls."  (Are 
you  afraid?)  "Not  now,  I  have  been  afraid  of  everything  on 
Earth  ever  since  my  mother  died."  (What  do  you  mean?)  "No 
one  would  look  at  me  or  talk  to  me — they  said  I  was  a  bad  girl, 
but  I  was  pure."  Again  she  said,  "They  laughed  about  me,  talked 
about  me — and  they  drew  up  a  play  about  me — Devil's  Island." 
Or  she  spoke  about  having  had  stomach  trouble,  bowel  trouble, 
teeth  trouble,  eye  trouble,  compound,  complicated  trouble.  (What 
do  you  mean?)  "Father  scolding  all  the  time,  he  sent  me  to  get 
bug  medicine  (true).  God  gives  that  medicine  to  the  one  that 
started  all  the  trouble — Devil's  Island." 

She  soiled  her  bed  and  was  asked  why  she  did  it.  She  said 
"I  have  been  transformed  into  a  baby,  the  Lord  said  I  was  too 


MALIGNANT  STUPORS  219 

pure  to  be  a  woman — I  had  to  become  a  baby  to  save  the  world." 
Or  when  asked  her  name  she  called  herself  "Baby  Chadwick  of 
the  whole  world — divine  Irish  Catholic  World — Amen/'  or  again 
"I  am  the  Roman  Catholic  Irish  Divine  Baby." 

Although  she  was  not  essentially  disoriented  she  called  the  place 
"mid-heaven,"  or  "a  holy  house,  sort  of  a  hospital."  She  also 
said,  "In  two  years  more  there  will  be  a  new  world  and  it  will 
be  more  happy  and  holy." 

The  day  after  entrance  the  patient,  though  in  part  as  de- 
scribed, had  a  spell  when  she  kept  her  eyes  closed  and  was  rigid. 
Spells  like  these  returned.  (About  a  month  after  admission  she 
became  completely  stuporous.)  She  prayed  at  times,  at  other 
times  was  constrained,  or  kept  her  eyes  closed.  Her  orientation 
throughout  was  good.  The  content  of  her  psychosis,  in  addition 
to  the  praying  attitude,  had  a  more  or  less  vague  religious 
coloring.  Thus  she  called  the  hospital  the  "House  of  God." 
Again,  when  on  one  occasion  she  had  jumped  at  the  window 
guard  and  was  asked  "why?"  she  said  "holy  communion."  Again 
she  said  she  was  "Mary,  Virgin  Mother."  But  this  religious  trend 
was  intermingled  with  remarkable  elements  of  another  sort.  Thus 
when  in  order  to  study  her  knowledge  of  the  events  after  admis- 
sion, she  was  asked  what  she  had  done  when  she  was  brought 
into  the  ward,  she  said,  "I  went  into  the  sanctuary  where  my 
bowels  moved  and  water  passed  from  me."  (Why  do  you  call  it 
sanctuary?)     "Because  Jesus  did  the  same  thing  I  did." 

Possibly  vague  sexual  allusions  are  also  contained  in  the  fol- 
lowing :  She  said  one  day  to'  the  doctor,  "Everything  went  wrong 
last  night,  good,  pure,  true  and  holy  doctor,  I  led  you  astray  and 
you  were  dying  last  night,  may  the  Almighty  God  forgive  me, 
I  ought  to  have  died,  but  I  fought  it  out,  for,  if  I  had  died,  my 
mother's  soul  would  not  have  been  saved  in  Heaven  and  from  the 
flames  of  Hell."  Again,  "I  will  not  look  at  you  again,  good, 
pure,  holy  doctor  of  the  world."  (Why?)  "I  am  afraid  I  will 
lead  you  astray."  And  also :  "I  led  James.  Peter  astray  too." 
It  should  be  added  that  she  sometimes  masturbated  rather 
shamelessly. 

She  said  she  heard  her  mother's  voice.  (What  did  she  say?) 
"Something  in  the  sky  for  me,  angels  call  for  me."  (What  do  the 
angels  say?)     "The  name  of  my  good  mother  in  Heaven."    Again 


220  BENIGN  STUPORS 

she  said  she  had  heard  her  mother  the  night  she  came  here. 
(What  did  she  say?)  "It  was  like  a  voice — feed  the  calf — that 
means  me,  I  suppose." 

Then  after  a  month  the  stupor  became  more  continuous.  She 
lay  totally  inactive  for  the  most  part,  had  to  be  fed,  soiled 
herself,  drooled  saliva,  was  at  times  cataleptic,  often  rigid.  Her 
limbs  became  cyanotic.  A  few  times  tears  were  seen.  On  other 
occasions  she  whispered  "peace,"  or  "peace  for  hazing,"  or  "pray 
— peace,"  or  "I  like  to  be  good."  Usually  no  responses  could  be 
obtained. 

After  some  months  she  was  at  times  seen  laughing.  This 
gradually  passed  into  a  state  of  total  disinterestedness  and  in- 
accesibility.  She  could  finally  be  made  to  polish  the  floor  in  an 
automatic  fashion,  but  never  spoke,  and  five  years  after  admis- 
sion she  was  transferred  to  another  hospital,  where  she  died 
(eleven  years  after  admission  to  the  ward  of  the  Institute)  with- 
out any  change  in  her  mental  condition  having  taken  place. 

Case  24. — Adele  M.  Age:  22.  Admitted  to  the  Psychiatric 
Institute  November  11,  1904. 

P.  H.  The  father  stated  that  the  patient  was  always  "cranky," 
had  outbursts  of  temper,  even  when  a  small  child  and  was  quar- 
relsome; also  said  that  she  was  "seclusive,"  had  few  friends,  was 
averse  to  meeting  people,  never  had  a  beau.  She  was  taken  out 
of  school  at  14  because  she  was  not  promoted  on  two  successive 
occasions  from  the  same  class.  Then  she  was  put  to  work,  but 
she  was  usually  discharged  for  incompetency. 

Onset  of  Psychosis:  Three  years  before  admission  it  was 
noted  that  she  laughed  occasionally  without  cause.  She  was  idle. 
This  laughing,  and  also  crying,  was  sometimes  more  frequent, 
again  less  noticeable. 

Six  months  before  admission  she  began  to  say  she  wanted  to 
leave  home,  but  made  no  move  to  do  so.  Then  she  began  to  speak 
of  bad  odors,  made  some  remarks  about  the  neighbors  talking 
about  her — saying  she  should  kill  herself;  again  she  said  the 
family  would  be  brought  to  death,  or  the  mother  was  falling  to 
pieces,  the  father  looked  sick.  She  also  said  her  head  was  swelling 
and  was  getting  thick.  Finally  she  wanted  to  hire  a  furnished 
room  and  kill  herself  and  asked  if  75  cents  which  she  had  was 
enough  to  do  it  with. 


MALIGNANT  STUPORS  221 

Two  weeks  before  admission  she  left  home,  wandered  about 
all  night,  was  picked  up  by  the  Salvation  Army,  and  returned 
to  her  home.     She  said  she  wanted  to  die. 

At  the  Observation  Pavilion  she  stated  that  her  mother  was 
falling-  to  pieces  and  her  father  sick.  She  also  said  she  wanted 
to  die.  "■''■'  1^^ 

Under  Observation:  The  patient  was  at  first  petulant,  saying 
"I  don't  want  to  stay  here,"  turning  her  face  away  from  the 
doctor,  generally  uninterested.  Though  it  could  be  established 
that  she  was  quite  oriented,  often  her  answers  were  "I  don't 
know,"  or  she  did  not  answer.  But  she  was  also  seen  crying  at 
times,  and  she  was  apt  to  bite  her  finger  nails.  She  had  to  be 
tube-fed.  Gradually  these  tendencies  increased  so  that  she  lay 
in  her  bed  with  head  covered,  saying  in  a  peevish  tone,  when 
spoken  to,  "Oh,  let  me  alone."  And  for  years  she  was  mute,  lying 
with  her  head  covered,  tube-fed.  When  reexamined  in  1914  (ten 
years  later),  she  was  found  lying  in  bed  with  an  empty  smile. 
There  was  paper  stuffed  in  her  ears.  When  approached,  she 
turned  her  head  away  and  would  not  talk. 

Case  25. — Catherine  W.  Age :  42.  Admitted  to  the  Psychiatric 
Institute  November  11,  1904. 

F.  H.  The  father  died  at  75,  the  mother  at  44.  Two  sisters 
died  of  tuberculosis.  A  brother  wanted  to  marry  but  was  op- 
posed by  the  father;  he  set  fire  to  the  house  of  the  girl  and  then 
drowned  himself. 

P.  H.  The  patient  came  to  this  country  when  20,  and  worked 
for  some  years  as  a  servant.  Then  she  married  after  a  short 
acquaintance.  The  husband,  according  to  his  own  statement, 
drank,  and  there  was  friction  from  the  first.  She  left  him  a  few 
weeks  after  marriage,  and  a  few  months  later  he  went  to  Ireland ; 
she  also  went  some  time  later  but  did  not  go  to  see  him.  Then 
they  lived  together  again.  They  had  four  children,  but  had  had 
no  intercourse  for  nine  years. 

Development  of  Psychosis:  Eight  years  before  admission  the 
patient  became  nervous,  slept  badly,  but  got  better.  It  was 
claimed  that  for  six  years  she  had  been  quieter  and  more  sullen 
than  before.  Three  years  before  admission  the  patient  had  to 
take  a  place  as  janitress,  since  she  needed  the  money.  From  the 
first  she  had  trouble  with  the  tenants  and  accused  everybody  of 


222  BENIGN  STUPORS 

being  in  league  against  her.  Some  six  or  eight  weeks  after  she 
had  taken  the  position,  she  developed  what  was  called  -typhoid 
fever,  and  some  time  later  the  daughter  came  down  with  the  same 
disease.  After  the  typhoid  she  was  more  antagonistic  towards 
her  husband,  accused  him  of  infidelity,  repeatedly  locked  him  out 
of  the  house,  but  continued  to  do  her  housework.  About  six 
months  after  this  illness  she  left  her  home,  but  returned  in  a 
week.  She  had  vague  ideas  thereafter  that  the  priests  were  saying 
things  against  the  family,  and  she  often  quarreled  with  the 
tenants.  For  a  year  she  had  done  no  work  but  sat  about.  Ten 
days  before  admission  she  stopped  eating. 

Under  Observation:  The  patient  was  mute,  stolid,  gazing 
straight  ahead,  sometimes  cataleptic.  She  had  to  be  tube-fed, 
was  usually  very  resistive  to  any  passive  motions ;  quite  often  she 
retained  her  urine,  but  she  did  not  hold  her  saliva.  Yet  there 
was  some  quick  responses  at  least  in  the  beginning.  At  such 
times  it  was  found  that  she  was  oriented,  but  nothing  could  ever 
be  obtained  about  her  feelings,  etc.,  except  that  she  once  said, 
when  asked  whether  she  was  worried,  that  she  "felt  weak,"  had 
"nothing  to  worry  about."  Occasionally  she  was  seen  to  cry 
silently;  at  times  she  would  breathe  faster  when  questioned,  or 
flush;  once  she  took  hold  of  the  doctor's  hand  when  he  questioned 
her,  and  cried,  but  made  no  reply.  On  another  occasion  she  was 
affectionate  to  her  son,  kissed  him,  although  she  paid  no  attention 
to  her  daughter  who  accompanied  the  son.  Later  she  said  to  the 
nurses,  "He  is  the  best  son  that  ever  lived."  But  more  and  more 
she  became  disinterested,  totally  inaccessible,  resistive,  had  to  be 
tube-fed.  In  this  condition  she  remained  for  five  and  a  half 
years.    At  the  end  of  that  time  she  died  of  tubercular  pneumonia. 


CHAPTEE  XII 


DIAGNOSIS  OF  STUPOR 


In  any  functional  psychosis  an  ofQiand  diagnosis 
is  dangerous.  When  one  deals  with  such  a  condition 
as  stupor,  however,  the  problem  is  exacting,  for, 
although  '' stupor"  may  be  seen  at  a  glance,  what  is 
seen  is  really  only  a  symptom  or  a  few  symptoms. 
'^ Stupor,"  then,  is  more  of  a  descriptive  than  a  diag- 
nostic term.  The  real  problem  is  to  determine  the 
psychiatric  group  into  which  the  case  should  be 
placed.  This  is  a  difficult  task,  for  the  differential 
diagnosis  rests  on  the  observation  and  utilization 
of  minute  and  unobtrusive  details.  A  correct  in- 
terpretation can  be  only  reached  by  obtaining  a 
complete  history  of  the  onset  and  observing  the 
behavior  and  speech  of  the  patient  for  a  long 
period,  usually  of  weeks,  sometimes  of  months. 
With  these  precautionary  words  in  mind,  it  may 
be  well  to  summarize  briefly  the  diagnostic  prob- 
lems in  connection  with  benign  stupor. 

In  the  first  place  one  naturally  considers  the  dif- 
ferentiation from  conditions  of  organic  stupor  or 
coma.  Since  psychotic  stupors  never  develop  with- 
out some  signs  of  mental  abnormality,  the  history 
is    usually   a    sufficient   basis    for   final    judgment. 

223 


224  BENIGN  STUPORS 

In  case  no  anamnesis  is  obtainable  the  functional 
nature  of  the  trouble  may  be  recognized  by  the  ab- 
sence of  those  physical  signs  which  characterize  the 
organic  stupors.  One  sees  no  violent  changes  in  res- 
piration, pulse  or  blood-pressure,  such  as  are  pres- 
ent in  the  intoxication  comas  of  diabetes  or  ne- 
phritis. There  is  no  characteristic  odor  to  the 
breath,  and  the  urine  is  relatively  normal.  The  un- 
consciousness of  trauma  or  apoplexy  is  accompanied 
by  focal  neurological  signs.  Even  in  aerial  concus- 
sion (so  frequently  seen  in  the  war)  where  no  one 
part  of  the  brain  is  demonstrably  affected  more  than 
another,  there  are  neurological  evidences  of  what 
one  might  call  '^physiological"  unconsciousness. 
The  eyes  roll  independently,  the  pupils  fail  to  react 
to  light.  On  the  other  hand,  there  are  definite  symp- 
toms characteristic  of  the  functional  state.  Mental 
activity  is  evidenced  by  a  muscular  resistiveness  or 
retention  of  urine.  Even  in  states  of  complete  re- 
laxation the  eyes  move  in  unison,  the  pupils  react 
to  light,  and  almost  universally  the  corneal  reflex  is 
present.  The  patient  appears  in  a  deep  sleep  rather 
than  actually  unconscious. 

The  post-epileptic  sleep  may  resemble  a  stupor 
strongly.  But  this  condition  is  temporary  and  the 
situation  and  appearance  of  the  patient  betrays  the 
fact  that  he  has  just  had  a  convulsion.  Rarely,  pro- 
tracted stuporous  states  occur  in  epilepsy  which 
closely  resemble  the  conditions  described  in  this 
book.     In  fact  it  is  probable  the  true  stupors  may 


DIAGNOSIS  OF  STUPOR  225 

occur  in  epilepsy  just  as  in  dementia  prsecox   or 
manic-depressive  insanity. 

There  is  usually  little  difficulty  in  the  discrimina- 
tion of  hysterical  stupor.  Occasionally  it  shows, 
superficially,  a  similarity  to  the  manic-depressive 
type.  Fundamentally,  there  is  a  wide  divergence 
between  the  two  processes,  in  that  in  the  hysterical 
form  a  dissociation  of  consciousness  takes  place, 
the  patient  living  in  a  reminiscent,  imaginary  or 
artificially  suggested  environment,  while  in  a  true 
stupor  there  is  a  withdrawal  of  interest  as  a  whole 
and  a  consequent  diffuse  reduction  of  all  mental 
processes.  This  difference  is  sooner  or  later  mani- 
fested by  the  appearance  in  the  hysteric  of  conduct 
or  speech  embodying  definite  and  elaborated  ideas. 

As  has  been  stated  fully  in  the  last  chapter  (to 
which  the  reader  is  referred),  the  stupor  of  demen- 
tia praecox  is  to  be  differentiated  from  that  of  manic- 
depressive  insanity  by  the  inconsistency  of  the 
symptoms  in  the  former  and  the  appearance  of  de- 
mentia praecox  features  during  the  stupor,  such  as 
inappropriate  affect,  giggling,  or  scattering.  Fur- 
ther, the  nature  of  the  disorder  is  usually  manifest 
before  the  onset  of  the  stupor  as  such. 

Sometimes  very  puzzling  cases  occur  in  more  ad- 
vanced years  when  it  is  difficult  to  say  whether  one 
is  dealing  with  involution  melancholia  or  stupor. 
Such  patients  show  inactivity,  considerable  apathy 
and  wetting  and  soiling,  and  with  these  a  whining 
hypochondria,  negativism,  and  often  a  rather  mawk- 
ish sentimental  death  content  without  the  dramatic 


226  BENIGN  STUPORS 

anxiety  which  usually  characterizes  the  involution 
state.  In  these  cases  the  diagnosis  is  bound  to  be 
a  matter  of  taste.  In  our  opinion  it  is  probably 
better  to  regard  these  as  clinically  impure  types. 
They  may  be  looked  on  as,  fundamentally,  involu- 
tion melancholias  (the  course  of  the  disease  is  pro- 
tracted, if  not  chronic)  in  whom  the  regressive  proc- 
ess characteristic  of  stupor  is  present  as  well  as 
that  of  involution. 

Great  difficulties  are  also  met  with  in  the  manic- 
depressive  group  proper.  So  often  a  stupor  begins 
with  the  same  indefinite  kind  of  upset  as  does  an- 
other psychosis  that  the  development  may  furnish 
no  clew.  Any  condition  where  there  is  inactivity, 
scanty  verbal  productivity  and  poor  intellectual  per- 
formance resembles  stupor.  This  triad  of  symp- 
toms occurs  in  retarded  depressions,  in  absorbed 
manic  states  and  in  perplexities.  Negativism  and 
catalepsy  are  never  well  developed  except  in  stupor. 
So  if  these  symptoms  be  present  the  diagnosis  is 
simplified.  But  they  are  often  absent  from  a  typical 
stupor.  Let  us  consider  these  three  groups  sepa- 
rately. 

The  most  important  difference  between  stupor 
and  depression  lies  in  the  affect.  Although  inactive 
and  sometimes  appearing  dull  the  depressive  indi- 
vidual is  not  apathetic  but  is  suffering  acutely.  He 
feels  himself  wicked,  paralyzed  by  hopelessness,  and 
finds  proof  of  his  damnation  in  the  apparent  change 
of  the  world  to  his  eyes  and  in  the  slowness  of  his 
mind.    But  he  is  acutely  aware  of  these  torments. 


DIAGNOSIS  OF  STUPOR  227 

The  stupor  patient,  on  the  other  hand,  does  not  care. 
He  is  neither  sad  nor  happy  nor  anxious.  This 
contrast  is  revealed  not  only  by  the  patients'  utter- 
ances but  by  their  expressions.  The  stuporous  face 
is  empty,  that  of  the  other  lined  with  melancholy. 
The  intellectual  defect,  too,  is  different.  In  retarded 
depression  the  patient  is  morbidly  aware  of  difficulty 
and  slowness,  but  on  urging  often  performs  tests 
surprisingly  well.  In  the  stupor,  however,  one  is 
faced  with  an  unquestionable  defect,  a  sheer  intel- 
lectual incapacity. 

In  Chapter  VIII  the  differential  diagnosis  be- 
tween perplexity  and  stupor  has  already  been 
touched  upon.  Here  again  the  affect  is  a  point  of 
contrast.  The  patient  has  not  too  little  emotion 
but  too  much.  The  feeling  of  intangible,  puzzling 
ideas  and  of  an  insecure  environment  causes  the 
subject  distress,  of  which  complaint  is  made  and 
which  can  be  witnessed  in  the  furrowed  brow  and 
constrained  expression.  There  is  also,  as  we  have 
seen,  a  rich  ideational  content  in  these  cases,  if  one 
can  get  at  it.  The  mind  is  not  a  blank,  as  in  the 
stupor,  or  concerned  only  with  delusions  of  death. 

Finally,  there  are  the  absorbed  manic  states. 
These  are  the  most  difficult,  inasmuch  as  the  patient 
is  often  so  withdrawn  and  so  introverted  that  at  any 
given  interview  there  may  be  no  objective  evidence 
of  mood  or  ideas.  Here  the  development  of  the 
psychosis  is  often  an  aid  to  diagnosis.  The  patient 
passes  through  phases  of  hypomania  to  great  exul- 
tation, the  flight  becomes  less  intelligible,  with  this 


228  BENIGN  STUPORS 

the  activity  diminishes  until  finally  expression  in  any 
form  disappears.  If  this  sequence  has  not  been  ob- 
served, continued  observation  tells  the  tale.  The 
patient  still  has  his  ideas  and  may  be  seen  smiling 
contentedly  over  them  (not  vacuously  as  does  the 
schizophrenic)  or  he  may  break  into  some  prank  or 
begin  to  sing.  Any  protracted  familiarity  with  the 
case  leads  to  a  conviction  that  the  patient's  mind  is 
not  a  blank,  but  that  his  attention  is  merely  directed 
exclusively  inward.  Then,  too,  when  his  ideas  are 
discovered,  it  is  found  that  they  are  not  exclusively 
occupied  with  the  topic  of  death. 


CHAPTEE  XIII 
TEEATMENT  OF  STUPOR 

In  dealing  with  cases  of  benign  stupor  the  first 
duty  of  physician  and  nurse  is  naturally  the  physical 
hygiene  of  the  patient.  More  is  needed  to  be  done 
in  the  bodily  care  of  these  persons  than  for  most  of 
the  inmates  of  our  hospitals  for  the  insane.  It  is 
perhaps  no  exaggeration  to  claim  that  a  deeply 
stuporous  patient  needs  as  much  attention  as  a  suck- 
ling babe.  In  the  first  place,  the  patient  must  be 
fed.  It  is  important  for  mental  recovery  that  the 
individual  in  stupor  should  be  stimulated  to  effort 
as  much  as  possible.  Consequently  there  is  an  econ- 
omy of  time  in  the  long  run  in  taking  pains  to  get 
the  patient  to  feed  himself  in  so  far  as  that  is  pos- 
sible. He  should  be  led  to  the  table  and  assisted 
in  handling  his  own  spoon  and  cup.  If  this  is  not 
practicable,  he  should  then  be  spoon-fed,  and  if  this 
in  turn  is  found  to  be  out  of  the  question,  tube-feed- 
ing should  be  resorted  to.  But  this  last  should 
never  be  looked  on  as  a  permanent  necessity,  but 
only  as  a  method  of  maintaining  the  patient's  health 
until  such  time  as  he  may  be  capable  of  independent 
taking  of  nourishment.  In  exactly  the  same  way  it 
is  of  prime  importance  to  get  the  patient  to  attend 

229 


230  BENIGN  STUPORS 

to  the  natural  habits  of  excretion.  He  should  be 
led  to  the  toilet  or  to  a  chair  commode,  and  efforts 
to  this  end  should  be  persistent,  just  as  are  those 
of  a  good  child's  nurse  who  has  the  ambition  of 
making  her  charge  develop  normal  habits.  Natu- 
rally those  who  retain  urine  and  feces  should  be 
watched  to  see  that  this  retention  does  not  last  long 
enough  to  menace  health.  The  physical  aspects  of 
treatment  are  exhausted  with  consideration  for 
cleanliness.  On  account  of  the  stupor  patients'  in- 
activity and  frequent  tendency  to  wetting  and  soil- 
ing, this  is  a  particularly  important  consideration. 
It  goes  without  saying  that  the  perineal  region 
should  be  kept  scrupulously  clean.  If  any  infections 
are  to  be  avoided,  eyes,  nose  and  mouth  should  also 
be  cleansed  frequently.  A  patient  who  is  so  indif- 
ferent as  to  keep  the  eyelids  open  for  such  a  long 
time  that  the  sclera  dry  and  ulcerate  is  also  apt  to 
let  flies  settle  and  produce  serious  ophthalmic  dis- 
ease. 

Less  obvious  and  more  important  are  the  meas- 
ures undertaken  for  the  mental  hygiene  of  the  case. 
On  account  of  the  tendency  present  in  so  many  pa- 
tients for  sudden  action  while  in  the  midst  of  an  ap- 
parently deep  and  permanent  inactivity,  it  is  neces- 
sary that  these  cases  be  not  isolated  but  remain 
under  constant  observation.  This  is  particularly 
true  of  those  who  have  demonstrated  impulsive  sui- 
cidal explosions. 

Not  only  on  the  basis  of  the  psychological  theory 
of  the  stupor  process,  but  from  the  observed  phe- 


TREATMENT  OF  STUPOR  231 

nomena  of  recovery,  we  gather  that  mental  stimu- 
lation is  of  first  importance  if  an  amelioration  of 
the  condition  is  to  be  attempted.  If  the  stupor  re- 
action be  a  regression,  which  is  essentially  a  with- 
drawal of  interest  and  energy  rather  than  a  fixation 
on  a  false  object,  then  excitement  is  desirable  and  in- 
terest must  be  reawakened.  The  withdrawal  is 
temporary  (inasmuch  as  the  psychosis  is  benign), 
but  just  as  a  normal  person  wakes  more  readily  on 
a  clear  sunshiny  day  than  when  it  rains,  so  the  more 
cheering  the  environment  the  more  rapid  the  re- 
covery. 

Consequently,  although  trying  to  those  in  charge, 
persistent  attention  should  be  given  the  patient. 
Feeding  and  hygienic  measures  probably  have  con- 
siderable value  in  this  work.  As  soon  as  it  is  at  all 
possible  the  patients  should  be  got  out  of  bed  and 
dressed.  When  up,  efforts  should  be  directed  to- 
wards making  them  do  something,  even  if  it  be  some- 
thing as  simple  as  pushing  a  floor  polisher.  On  ac- 
count of  their  lack  of  enthusiasm  the  stupor  cases 
are  often  omitted  from  the  list  of  those  given  occu- 
pation and  amusement.  Even  if  they  go  through 
the  motions  of  work  or  play  with  no  sign  of  interest, 
such  exercise  should  not  be  allowed  to  lapse.  Then, 
too,  the  environment  should  be  changed  when  prac- 
ticable. A  patient  may  improve  on  being  moved 
to  another  building. 

Perhaps  the  most  potent  stimulus  that  we  have 
observed  is  that  of  family  visits.  In  most  manic- 
depressive   psychoses    visits    of   relations   have    a 


232  BENIGN  STUPORS 

bad  effect.  The  patients  become  excited,  treat  the 
visitors  rudely,  perhaps  even  assault  them,  and  all 
their  symptoms  are  aggravated.  But  the  stupor 
needs  excitement,  and  an  habitual  emotional  interest 
is  more  apt  to  arouse  him  than  an  artificial  one. 
In  another  point  the  situation  differs.  As  a  rule 
manic-depressive  patients  have  delusional  ideas  or 
attitudes  in  connection  with  their  nearest  of  kin, 
so  that  contact  with  these  stirs  up  the  trouble. 
The  stupor  regression  going  beneath  the  level  of 
such  attachments  leaves  family  relationships  rela- 
tively undisturbed.  Hence,  while  the  visit  of  a  hus- 
band is  likely  to  produce  nothing  but  vituperation 
or  blows  from  a  manic  wife,  the  stuporous  woman 
may  greet  him  affectionately  and  regain  thereby 
some  contact  with  the  world. 

So  many  cases  begin  recovery  in  this  manner  that 
it  cannot  be  mere  chance.  One  patient's  improve- 
ment, for  instance,  dated  definitely  from  the  day  a 
nurse  persuaded  her  to  write  a  letter  home.  It  is 
striking,  too,  how  quickly  a  patient,  while  somewhat 
dull  and  slow,  will  brighten  up  when  allowed  to  re- 
turn home.  A  similar  improvement  under  these 
circumstances  is  often  seen  in  partially  recovered 
cases  of  involution  melancholia,  in  whom  a  psycho- 
logical regression  similar  to  that  of  stupor  takes 
place.  Such  experiences  make  one  wonder  whether 
perhaps  these  alone  of  all  our  insane  patients  would 
not  recover  more  quickly  at  home  than  in  hospitals, 
provided  nursing  care  could  be  given  them. 

This  is  a  mere  suggestion.     Before  treatment  can 


TREATMENT  OF  STUPOR  233 

be  rational  the  nature  of  any  disease  process  must 
be  known,  and  we  do  not  pretend  to  have  done  more 
as  yet  than  outline  the  probable  mental  pathology 
of  the  benign  stupors.  The  next  step  is  to  put 
theory  into  practice  and  experiment  widely  with 
various  means  to  see  if  by  appropriate  stimulation 
the  average  duration  of  these  psychoses  cannot  be 
reduced.  It  is  largely  with  the  hope  of  inducing 
other  psychiatrists  to  carry  on  such  work  that  this 
book  is  written.  There  is  no  other  manic-depressive 
psychosis  which,  theoretically,  offers  such  hope  of 
simple  psychological  measures  being  of  therapeutic 
value. 


CHAPTER  XIV 

SUICMARY  OF  THE  STUPOR  REACTION 

Having  discussed  in  detail  the  various  symptoms 
and  theoretic  aspects  of  the  benign  stupors,  it  may 
be  well  to  have  these  observations  and  speculations 
summarized. 

It  being  established  that  stupors  occur  as  a  tem- 
porary form  of  insanity  ^  psychiatry  is  faced  at  once 
with  the  problem  of  describing  these  conditions  accu- 
rately in  order  to  ascertain  their  nosological  posi- 
tion. To  this  end  we  first  examined  typical  cases  of 
deep  stupor  and  found  that  the  clinical  picture  is 
made  up  of  the  following  symptoms :  In  the  fore- 
ground stands  poverty  of  affect.  The  patients  are 
ilmost  unbelievably  apathetic,  giving  no  evidence  by 
peech  or  action  of  interest  in  themselves  or  their  en- 
vironment, unmoved  even  by  painful  stimuli.  Their 
faces  are  wooden  masks;  their  voices  as  colorless 
when  words  are  uttered.  In  some  cases  sudden  mood 
reactions  break  through  at  rare  intervals.  The  sec- 
ond cardinal  symptom  is  inactivity.  As  a  rule  there 
is  a  complete  cessation  of  both  spontaneous  and  reac- 
tive movements  and  speech.     So  profound  may  this 

^  Kirby,  George  H. :  ' '  The  Catatonic  Syndrome  and  Its  Eelation 
to  Manic-Depressive  Insanity."  Jow.  of  Nervous  and  Mental  Dis- 
ease, Vol.  XL,  No.  11,  1913. 

234 


SUMMARY  OF  THE  STUPOR  REACTION    235 

inhibition  be  that  swallowing  and  blinking  of  the 
eyes  are  often  absent.  The  trouble  is  not  a  paral- 
ysis, however,  for  reflexes  without  psychic  com- 
ponents are  unaffected.  Possibly  related  to  the  in- 
activity is  the  preservation  of  artificial  positions 
which  is  called  catalepsy,  a  fairly  frequent  phe- 
nomenon. A  tendency  opposite  to  the  inactivity  is 
seen  in  negativism.  This  perversity  is  present  in 
all  gradations  from  outbursts  of  anger  with  blows 
and  vituperation  to  sullen,  or  even  emotionless,  mus- 
cular rigidity.  This  last  occurs  most  often  when  the 
patient  is  approached  but  may  be  seen  when  obser- 
vations are  made  at  a  distance.  Frequently  wetting 
and  soiling  are  due  to  negativism,  when  the  patient 
has  been  led  to  the  toilet  but  relaxes  the  sphincters 
so  soon  as  he  leaves  it.  A  constant  feature  is  a 
thinking  disorder.  On  recovery  memory  is  largely 
a  blank  even  for  striking  experiences  during  the 
psychosis  and,  when  accessible  during  the  stupor 
to  any  questioning,  a  failure  of  intellectual  functions 
is  apparent.  An  ideational  content  may  be  gath- 
ered while  the  stupor  is  incubating,  during  interrup- 
tions, or  from  the  recollections  of  recovered  pa- 
tients. Its  peculiarity  is  a  preoccupation  with  the 
theme  of  death,  which  is  not  merely  a  dominant 
topic  but,  often,  an  exclusive  interest.  Probably  to 
be  related  to  this  is  a  tendency,  present  in  some 
cases,  to  sudden  suicidal  impulses,  that  are  as  ap- 
parently planless  and  unexpected  as  the  conduct  of 
many  catatonios.  Finally  the  disease  is  prone  to 
exhibit  certain  physical  peculiarities.     A  low  fever 


236  BENIGN  STUPORS 

is  common  and  so  are  skin  and  circulatory  anoma- 
lies. A  loss  of  weight  is  the  rnle,  and  menstruation 
is  almost  always  suppressed. 

As  to  the  frequency  of  stupor  no  figures  are  avail- 
able, for  the  simple  reason  that  the  diagnosis  in  large 
clinics  has  not  been  made  with  sufficient  accuracy 
to  justify  any  statistics.  Most  of  these  cases  are 
usually  called  catatonia,  depression,  allied  to  manic- 
depressive  insanity  or  allied  to  dementia  prsecox. 
The  majority  of  the  stupors  reported  in  this  book 
were  in  women,  but  this  is  merely  the  result  of 
chance,  since  it  has  been  easier  in  the  Psychiatric 
Institute  to  study  functional  psychoses  in  the  female 
division,  while  the  male  ward  has  been  reserved 
largely  for  organic  psychoses.  The  majority  of  the 
patients  seem  to  be  between  15  and  25  years  of  age, 
so  that  it  is,  presumably,  a  reaction  of  youthful 
years.  In  our  experience  most  cases  occur  among 
the  lower  classes,  which  agrees  with  the  opinion  of 
Wilmanns  who  found  this  tendency  among  pris- 
oners. 

This  gives  a  brief  description  of  the  deep  stupor. 
But  even  our  typical  cases  did  not  present  this  pic- 
ture during  the  entire  psychosis.  They  showed 
phases  when,  superficially  viewed,  they  were  not  in 
stupor  but  suffered  from  the  above  symptoms  as 
tendencies  rather  than  states.  There  are  also  many 
psychoses  where  complete  stupor  is  never  devel- 
oped. This  gives  us  our  justification  for  speaking 
of  the  stupor  reaction,  which  consists  of  these  symp- 
toms (or  most  of  them)  no  matter  in  how  slight  a 


SUMMARY  OF  THE   STUPOR  REACTION    237 

degree  they  may  be  present.  The  analogy  to  mania 
and  hypomania  is  compelling.  The  latter  is  merely 
a  dilution  of  the  former.  Both  are  forms  of  the 
manic  reaction.  We  consequently  regard  stupor  and 
partial  stupor  as  different  degrees  of  the  same  psy- 
chotic process  which  we  term  the  stupor  reaction. 
To  understand  it  the  symptoms  should  be  separately 
analyzed  and  then  correlated. 

The  most  fundamental  characteristic  of  the  stu- 
por symptoms  is  the  change  in  affect  which  can  be 
summed  up  in  one  word — apathy.  It  is  fundamen- 
tal because  it  seems  as  if  the  symptoms  built  around 
apathy  constitute  the  stupor  reaction.  The  emo- 
tional poverty  is  evidenced  by  a  lack  of  feeling, 
loss  of  energy  and  an  absence  of  the  normal  urge 
of  living.  This  is  quite  different  from  the  emotional 
blocking  of  the  retarded  depression,  for  in  the  latter 
the  patient  shows  either  by  speech  or  facial  expres- 
sion a  definite  suffering.  The  tendency  to  reduction 
of  affect  produces  two  effects  on  such  emotions  as 
internal  ideas  or  environmental  events  may  stimu- 
late. Exhibitions  of  emotion  are  either  reduced  or 
dissociated.  For  instance,  anxiety  is  frequently 
diminished  to  an  expression  of  dazed  bewilderment ; 
or,  isolated  and  partial  exhibitions  of  mood  occur,  as 
when  laughter,  tears  or  blushing  are  seen  as  quite 
isolated  symptoms.  This  latter — the  dissociation  of 
affect — seems  to  occur  only  in  stupor  and  dementia 
praecox.  It  should  be  noted,  however,  that  inappro- 
priateness  of  affect  is  never  observed  in  a  true  be- 
nign stupor.     A  final  peculiarity  is  the  tendency  to 


238  BENIGN  STUPORS 

interniption  of  the  apathetic  habit,  when  the  patient 
may  return  to  life,  as  it  were,  for  a  few  moments 
and  then  relapse. 

Closely  related  to  the  apathy,  and  probably 
merely  an  expression  of  it,  is  the  inactivity  which 
is  both  muscular  and  mental.  It  exists  in  all  grada- 
tions from  that  of  flaccidity  of  voluntary  muscles, 
with  relaxation  of  the  sphincters,  and  from  states 
where  there  is  complete  absence  of  any  evidence  of 
mentation  to  conditions  of  mere  physical  and  psy- 
chic slowness.  After  recovery  the  stupor  patient 
frequently  speaks  of  having  felt  dead,  paralyzed 
or  drugged. 

By  far  the  commonest  cause  of  emotional  expres- 
sion or  interruption  in  the  inactivity  is  negativism. 
This  is  a  perversity  of  behavior  which  seems  to  ex- 
press antagonism  to  the  environment  or  to  the 
wishes  of  those  about  the  patient.  In  the  partial 
stupors  it  is  seen  as  active  opposition  and  cantan- 
kerousness.  In  the  more  profound  conditions  it  is 
represented  by  muscular  resistiveness  or  rigidity, 
or  refusal  to  swallow  food  when  placed  in  the  mouth. 
Occasionally,  too,  the  patient  may  even  in  a  deep 
stupor  retain  urine  so  long  that  catheterization  is 
necessary.  All  the  explanations  which  one  may 
gather  from  the  patients'  own  utterances,  mainly 
retrospective,  seem  to  point  to  negativism  express- 
ing a  desire  to  be  left  alone.  The  appearance  of 
perverse  behavior  in  aimless  striking  or  mere  mus- 
cular rigidity  seems  to  be  an  example  of  dissociation 
of  affect. 


SUMMARY  OF  THE  STUPOR  REACTION    239 

Catalepsy  is  an  important  symptom  because,  al- 
though it  occurred  in  slightly  less  than  a  third  of  our 
cases,  it  seems  to  be  a  peculiarity  of  the  stupor  reac- 
tion found  but  rarely  in  other  benign  psychoses. 
It  seems  never  to  occur  without  there  being  some 
evidence  of  mental  activity,  and,  consequently,  we 
are  forced  to  conclude  that  it  is  of  mental  rather 
than  of  physical  origin.  Just  what  it  means  psy- 
chically it  is  impossible  to  state  without  much  more 
extended  observations.  We  conjecture  tentatively, 
however,  that  the  retention  of  fixed  positions  is  in 
part  merely  a  phenomenon  of  perseveration,  and  in 
part  an  acceptance  of  what  the  patient  takes  to  be 
a  command  from  the  examiner,  and  sometimes  a 
distorted  form  of  muscular  resistiveness. 

The  intellectual  processes  suffer  more  seriously 
in  stupor  than  in  any  other  form  of  manic-depres- 
sive insanity.  Not  only  do  the  deep  stupors  betray 
no  evidence  of  mentation  during  the  acme  of  the 
psychosis,  but  retrospectively  they  usually  speak  of 
their  minds  being  a  blank.  Incompleteness  and 
slowness  of  intellectual  operations  are  highly  char- 
acteristic features  of  the  partial  stupors  and  of  the 
incubation  period  of  the  more  profound  reactions. 
The  features  of  this  defect  are  a  difficulty  in  grasp- 
ing the  nature  of  the  environment,  a  slowness  in 
elaborating  what  impressions  are  received,  with  re- 
sulting disorientation,  poor  performance  of  any  set 
tests  and  incomplete  memory  for  external  events 
when  recovery  has  taken  place.  At  times  the  think- 
ing disorder  may  develop  with  great  suddenness  or 


240  BENIGN  STUPORS 

improve  as  quickly,  and  a  tendency  to  isolated  evi- 
dences of  mental  acuity  is  another  example  of  the 
inconsistency  which  is  so  highly  characteristic  of 
stupor.  We  should  note,  however,  that  these  spo- 
radic exhibitions  of  mentality  are  always  associated 
with  brief  emotional  awakening. 

When  we  turn  to  examine  the  fragmentary  utter- 
ances of  stupor  patients,  we  are  surprised  by  the 
narrowness  and  uniformity  of  the  ideational  con- 
tent. It  seems  to  be  coniined  to  thoughts  of  death 
or  closely  related  conceptions.  Thirty-five  out  of 
thirty-six  consecutive  cases  at  one  time  or  another 
referred  literally  to  death.  It  is  commonest  during 
the  onset,  as  all  but  five  of  these  patients  spoke  of 
it  during  the  incubation  of  their  psychoses.  Hence 
we  conclude  that  death  ideas  and  stupor  are  consecu- 
tive phenomena  in  the  same  fundamental  process. 
As  two-thirds  of  the  series  interrupted  the  stupor  to 
speak  of  death  or  to  attempt  suicide,  we  assume 
that  this  relationship  persists.  Only  a  quarter  gave 
any  retrospective  account  of  these  fancies,  so  we 
presume  that  their  psychotic  experiences  were  re- 
pressed with  recovery. 

The  usual  form  in  which  the  idea  appears  is  as 
a  delusion  of  going  to  die  or,  literally,  of  being  dead. 
It  may  appear  as  being  in  Heaven  or  Hell.  A  theo- 
retically important  group  is  that  which  includes  the 
patients  who,  in  addition,  speak  of  being  in  situa- 
tions such  as  under  the  water  or  underground, 
which  we  have  mythological  and  psychological  evi- 
dence   to    believe    are    formulations    of    a.   rebirth 


SUMMARY  OF   THE   STUPOR  REACTION    241 

fantasy.  Not  rarely,  preoccupation  with  death  is 
expressed  in  sudden  impulsive  suicidal  attempts. 

The  affective  setting  of  these  different  formula- 
tions is  important.  A  delusion  of  literal  death  oc- 
curs with  complete  apathy.  The  wish  to  die  is  apt 
to  appear  without  the  usual  accompaniment  of 
sadness  or  distress  but  still  with  considerable 
energy  when  impulsive  suicidal  attempts  are  made. 
A  prospect  of  death,  particularly  when  there  is  antic- 
ipation of  being  killed,  is  apt  in  manic-depressive 
insanity  to  occur  in  a  setting  of  anxiety.  Similarly 
one  ordinarily  observes  fear  in  the  patient  who  has 
delusions  of  drowning  or  burial.  In  the  stupor  cases, 
however,  this  painful  affect  seems  to  be  reduced  to 
a  mere  dazed  bewilderment  or  feeble  exhibitions  of 
a  desire  for  safety,  such  as  the  slow  swimming  move- 
ments of  a  patient  who  thought  she  was  under  the 
water.  When  these  ideas  of  danger  become  allied 
to  everyday  interests — husband  or  child  imperiled, 
etc. — a  weak  affect  in  the  form  of  depression  is  apt 
to  occur. 

Physical  symptoms  are  more  common  than  in  any 
other  benign  psychosis.  Of  these  the  most  nearly 
constant  is  a  low  fever,  the  temperature  running  be- 
tween 99°  and  101°.  Twenty-eight  out  of  thirty-five 
cases  had  this  slight  elevation  with  a  tendency  for  it 
to  occur  immediately  at  the  beginning  of  marked 
stupor  symptoms.  Although  the  evidence  does  not 
positively  exclude  any  possibility  of  infection,  it 
speaks  distinctly  against  this  view.  A  possible  ex- 
planation is  that  the  low  fever  is  a  secondary  symp- 


242  BENIGN  STUPORS 

torn.  The  suprarenal  glands  may  function  insuffi- 
ciently as  a  consequence  of  the  emotional  poverty, 
since  all  emotions  which  have  been  experimentally 
studied  seem  to  stimulate  the  production  of  adre- 
nalin. Without  this  normal  hormone  for  the  activity 
of  the  sympathetic  nervous  system,  there  would  be  a 
disturbance  of  skin  and  circulatory  reactions  that 
would  interfere  with  the  normal  heat  loss.  Sug- 
gestive evidence  to  support  this  view  comes  from  the 
frequency  with  which  the  extremities  are  cyanotic 
or  cold,  the  skin  greasy,  sweating  profuse  or  absent, 
and  so  on.  Further  observations  are  necessary  to 
confirm  or  disprove  this  hypothesis,  but  we  feel  in- 
clined to  accept  it  tentatively  because  it  is  plausible 
and  consistent  with  the  view  that  stupor  is  essen- 
tially a  psychogenic  type  of  reaction.  Another 
physical  anomaly,  which  is  presumably  of  endocrine 
origin,  is  the  suppression  of  the  menses.  This  prob- 
ably results  from  lowered  nutrition.  In  some  cases 
it  ensues  directly  on  a  psychic  crisis  before  any 
nutritional  change  can  have  taken  place.  Finally, 
among  the  symptoms  of  possible  physical  origin, 
epileptoid  attacks  were  described  in  two  of  our 
oases.  This  is  chiefly  of  interest  in  that  such  phe- 
nomena are  extremely  rare  in  the  benign  psychoses. 
We  believe  that  the  mental  symptoms  summarized 
above  constitute  a  specific  psychotic  type  of  reaction 
capable  of  appearing  in  any  severity  from  mere 
lethargy  and  indifference  to  profound  stupor.  Since 
the  prognosis  is  good,  we  feel  obliged  to  classify  this 
with  the  manic-depressive  reactions.    Further  justi- 


SUMMARY  OF  THE  STUPOR  REACTION    243 

fication  for  this  grouping  is  found  in  the  occurrence 
of  the  stupor  reaction  as  a  phase  in  many  manic- 
depressive  psychoses.  A  patient  may  swmg  from 
mania  to  stupor  as  from  mania  to  depression,  and 
when  the  partial  stupors  are  recognized  as  milder 
forms  of  the  same  process,  it  seems  to  be  a  frequent 
type  of  reaction. 

If  stupor  be  a  reaction  type,  its  laws  must  be 
psychological.  According  to  the  view  of  modern 
psychopathology,  the  essence  of  insanity  is  regres- 
sion with  indolent  thinking  as  opposed  to  progres- 
sive and  energetic  mentation.  One  can  look  on 
stupor  as  being  a  profound  regression.  Effort  is 
abandoned  (apathy  and  inactivity),  while  the  idea- 
tional content  expresses  a  desire  for  a  retreat  from 
the  world  in  death.  It  is  possible  to  think  of  this 
regression  as  a  return  to  the  mental  habit  of  the 
suckling  period,  when  spontaneous  effort  is  at  its 
minimum.  This,  too,  is  the  time  when  petulance  and 
tantrums  are  frequent  expression  of  a  wish  to  be  left 
alone,  which  may  account  for  the  negativism  as  a 
consistent  symptom  of  the  same  regressive  progress. 

Just  as  we  regress  in  sleep,  to  rise  refreshed  for  a 
new  day's  duties,  so  the  stupor  case  often  shows  ex- 
cessive energy  in  a  hypomanic  phase  before  com- 
plete normality  is  reached.  This  corresponds  again 
to  the  age-old  association  of  the  ideas  of  death  and 
rebirth  which  we  see  together  so  frequently  in 
stupor.  It  is  the  psychology  of  wiping  the  slate 
clean  for  a  fresh  start. 

The  development  and  symptoms  of  stupor  furnish 


244  BENIGN  STUPORS 

evidence  in  support  of  the  hypothesis  of  this  type  of 
regression.  Dissatisfaction  of  any  kind  is  the  setting 
in  which  the  psychosis  begins  and  the  connnonest 
precipitating  factor  is  some  reminder  of  death.  That 
loss  of  energy  appears  with  the  stupor  is  evident 
from  the  inactivity  and  apathy,  while  the  thinking 
disorder  can  be  shown  to  be  the  result  of  the  same 
loss.  The  different  ^ levels''  of  the  stupor  reaction 
also  conform  to  a  theory  of  regression.  First  there 
is  mere  indifference  and  quietness;  then  appear 
false  ideas  when  normality  is  so  far  abandoned  as 
to  mean  a  loss  of  the  sense  of  reality;  withdrawal  of 
interest  from  the  environment,  with  its  consequent 
centering  of  self,  leads  to  the  next  stage — that  of  the 
spoiled  child  reaction;  then  follows  the  exclusion  of 
the  world  around  in  the  dramatization  of  death; 
finally,  in  the  deepest  stupor,  mentation  is  so  far 
abandoned  that  we  can  gather  no  evidence  of  even 
this  delusion  being  present. 

Atypical  features  in  stupor  have  to  do  mainly  with 
interruptions,  interludes  as  it  were,  of  elation, 
anxiety  or  perplexity.  These  are  explicable  as 
awakenings  from  the  nothingness  of  stupor  into 
imaginations  such  as  characterize  the  other  manic- 
depressive  psychoses.  When  such  tendencies  are 
present,  the  co-existence  of  the  stupor  process  may 
tone  down  the  emotional  response  or  prevent  its 
complete  repression  so  that  insufficient  or  dissoci- 
ated affects  appear.  A  combination  of  the  stupor 
tendency  to  apathy  with  the  mood  of  another  reac- 


SUMMARY  OF  THE  STUPOR  REACTION    245 

tion  is  probably  the  only  combination  of  affects  to 
be  met  with  in  psychiatry. 

The  stupor  reaction,  then,  is  a  simple  regression, 
with  a  limitation  of  energy,  emotion  and  ideational 
content,  the  last  being  confined  to  notions  of  death. 
All  functional  psychoses  are  regressions.  How  do 
the  others  differ  from  this?  We  need  only  answer 
this  question  in  so  far  as  it  concerns  the  clinical 
states  resembling  benign  stupors.  Stupors  occur 
frequently  in  catatonic  dementia  prsecox.  In  this 
disease  there  is  a  regression  of  interest  to  primitive 
fantastic  thoughts,  and  with  this  a  perversion  of 
energy  and  emotion.  This  corrupts  the  purity  of  the 
stupor  picture  so  that  inconsistencies,  such  as  empty 
giggling,  atypical  delusions  and  scattered  speech, 
occur.  Other  impurities  are  to  be  found  in  the 
frequent  orientation  of  the  dementia  prsecox  stupor 
patient  which  is  discovered  to  be  astonishingly  good, 
or  in  free  speech  associated  with  apathy  and  inactiv- 
ity. Such  symptoms  usually  appear  quite  early  and 
should  enable  one  to  make  a  positive  diagnosis 
within  a  short  time  after  patient  comes  under  ob- 
servation. As  a  matter  of  fact,  in  many  if  not  most 
cases  there  is  a  slow  onset  characterized  by  the 
pathognomonic  symptoms  of  dementia  praecox  be- 
fore the  actual  stupor  sets  in. 

Other  psychoses  superficially  resembling  stupor 
are  the  perplexity  and  absorbed  manic  (manic 
stupor)  states.  We  have  reason  to  believe  that  both 
these  conditions  are  essentially  the  result  of  ab- 
sorption in  kaleidoscopic  ideas.     Their  appearance 


246  BENIGN  STUPORS 

is  that  of  inactivity  and  indifference  to  the  outside 
world,  just  as  a  dreamer  seems  placid  and  apathetic. 
But  these  reactions  are  not  without  emotion  which 
may  sometimes  be  obvious,  and  the  richness  of  the 
mental  content  is  sooner  or  later  manifest. 

Finally,  from  a  practical  standpoint,  an  important 
peculiarity  of  benign  stupor  is  the  tendency  for  re- 
sponse to  stimulation  in  amelioration  of  the  process. 
Close  attention  to  these  patients  is  advisable,  there- 
fore, not  merely  for  the  sake  of  their  physical  health, 
but  also  because  any  attention  tends  to  keep  them 
mentally  alive  or  revive  their  waning  energy.  Visits 
of  relations  often  initiate  recovery  in  a  striking  way. 
From  occurrences  such  as  these,  psychiatrists 
should  gain  hints  for  valuable  therapeutic  experi- 
ments. 

So  much  for  the  technical,  psychiatric  aspects  of 
the  stupor  problem.  We  have  frequently  spoken  of 
it,  however,  as  a  psychobiological  reaction.  If  this 
be  a  sound  view,  similar  tendencies  should  appear 
in  everyday  life,  the  psychotic  phenomena  being 
merely  the  exaggerations  of  a  fundamental  type  of 
human  and  animal  behavior.  Shamming  of  death  in 
the  face  of  danger  and  animal  catalepsy  come  to 
mind  at  once,  but  since  we  know  nothing  of  the  as- 
sociated affective  states  we  should  be  chary  of  using 
them  even  as  analogies.  We  are  on  safer  ground  in 
discussing  problems  of  human  psychology. 

It  is  evident  that  there  are  psychological  parallels 
between  the  stupor  reaction  and  sleep,  while  future 
work  may  show  physiological  similarities  as  well. 


SUMMARY  OF  THE   STUPOR  REACTION    247 

Apathy  towards  the  environment,  inactivity  and  a 
thinking  disorder  are  common  to  both.  But  sleep 
reactions  do  not  occur  in  bed  alone.  Weariness  pro- 
duces indifference,  physical  sluggishness,  inatten- 
tion and  a  mild  thinking  disorder  such  as  are  seen 
in  partial  stupors.  The  phenomena  of  the  midday 
nap  are  strikingly  like  those  of  stupor.  The  indi- 
vidual who  enjoys  this  faculty  has  a  facility  for  re- 
tiring from  the  world  psychologically  and  as  a  result 
of  this  psychic  release  is  capable  of  renewed  activity 
(analogous  to  post-stuporous  hypomania)  that  can- 
not be  the  result  of  physiological  repair,  since  the 
whole  affair  may  last  for  only  a  few  minutes. 

In  everyday  life  there  are  more  protracted  states 
where  the  comparison  can  also  be  made.  When  life 
fails  to  yield  us  what  we  want,  we  tend  to  become 
bored — a  condition  of  apathy  and  inactivity,  form- 
ing a  nice  parallel  to  stupor  inasmuch  as  external 
reminders  of  reality  and  demands  for  activity  are 
apt  to  call  out  irritability.  A  form  of  what  is  really 
mental  disease,  although  not  called  insanity,  is  per- 
manent boredom,  a  deterioration  of  interest,  energy 
and  even  intelligence  by  which  many  troubled  souls 
solve  their  problems.  A  sudden  withdrawal  from 
the  world  we  call  stupor.  When  the  same  thing 
happens  insidiously,  the  condition  is  labeled  accord- 
ing to  the  financial  and  social  status  of  the  victim. 
He  is  a  bum,  a  loafer,  a  mendicant  or,  more  politely, 
a  disillusioned  recluse.  Frequently  this  undiagnosed 
dement  has  satisfied  himself  with  a  weak,  cynical 
philosophy  that  life  is  not  worth  while. 


248  BENIGN  STUPORS 

It  is  but  a  step  from  valueless  life  to  death  and 
the  same  tendency  which  makes  the  patient  fancy  he 
is  dead,  leads  the  tired  man  to  sleep,  the  poet  to 
sigh  in  verse  for  dissolution,  and  the  myth  maker 
to  fabricate  rebirth.  The  religions  of  the  world  are 
full  of  this  yearning,  which  reaches  its  purest  ex- 
pression in  the  belief  and  philosophy  of  Nirvana. 
The  ideational  content  of  stupor  has  also  its  ana- 
logue in  crime.  The  desire  for  perpetuation  of  rela- 
tionships unprosperous  in  this  world  is  not  seen  only 
in  the  delusion  of  mutual  death.  One  can  hardly 
pick  up  a  newspaper  without  reading  of  some  un- 
happy man  or  woman  who  has  slain  a  disillusioned 
lover  and  then  committed  suicide. 


CHAPTER  XV 
THE  LITERATURE  OF  STUPOR  * 

The  cases  of  benign  stupor  which  we  report  here 
are  not  clinical  curiosities.  Taking  the  symptoms  as 
the  products  of  a  reaction  type,  the  latter  is  really 
quite  common.  One,  therefore,  asks  what  other 
psychiatrists  have  done  with  this  material.  How 
have  they  described  these  stupors,  how  classified 
them?  This  chapter,  essentially  an  appendix,  at- 
tempts to  give  a  brief  answer  to  this  inquiry.  No 
attempt  is  made  to  catalogue  all  that  has  been  writ- 
ten on  or  around  this  subject  but  only  to  mention 
typical  reports  and  viewpoints. 

The  French,  beginning  with  Pinel  in  the  18th 
Century,  were  the  first  to  write  extensively  of 
stupor.  An  excellent  paper  by  Dagonet  ^  appeared 
in  1872,  in  which  such  literature  as  had  appeared  up 
to  that  time  is  discussed.  He  defines  ^'Stupidity" 
as  a  form  of  insanity  in  which  ^* delirious"  ideas 
may  or  may  not  be  present,  which  has  for  its  char- 
acteristic symptoms  a  state  of  more  or  less  manifest 

*  This  chapter  has  been  written  mainly  from  material  in  Dr. 
Hoeh's  notes  which  was  manifestly  incomplete.  No  claim  is  made 
for  its  exhaustiveness.  The  Editor. 

^  Dagonet,  M.  H. :  "  De  la  Stupeur  dans  les  Maladies  Mentales  et 
de  1 'Affection  mentale  designee  sous  le  Nom  de  Stupidite. "  An- 
nates Medico-Psychologiques,  T.  VII,  5e  Serie,  1872. 

249 


250  BENIGN  STUPORS 

stupor  and  a  greater  or  less  incapacity  to  coordinate 
ideas,  to  elaborate  sensations  experienced  and  ac- 
complish voluntary  acts  necessary  for  adaptation. 
This  would  seem  to  include  our  ''partial  stupor,"  as 
well  as  the  more  marked  cases. 

He  quotes  an  excellent  definition  from  Louyer 
Villermay  (Diet,  des  sc.  med.  t.  LIII,  p.  67).  ''Stu- 
por is  a  term  applied  to  stupefaction  of  the  brain. 
It  is  recognizable  by  the  diminution  or  enfeeblement 
of  internal  sensation  and  by  a  greater  difficulty  in 
exercising  memory,  judgment  and  imagination.  It 
is  accompanied  by  a  general  numbness  and  a  weak- 
ness of  feeling  and  movement.  The  patient,  then, 
has  an  indefinite  and  stupid  expression,  he  under- 
stands questions  put  to  him  with  difficulty,  and 
answers  them  with  effort  or  not  at  all.  He  seems 
overwhelmed  with  sleep,  he  forgets  to  withdraw  his 
tongue  after  showing  it  to  the  doctor,  he  complains 
of  no  uncomfortable  sensation,  of  no  illness,  he 
seems  to  take  no  interest  in  what  goes  on  about  him. 
.  .  .  The  stupor  patient  is  a  fool  who  does  not  speak, 
in  this  being  more  tolerable  than  the  one  who  speaks 
[delightful  naivete!].  One  who  is  dumbfounded  by 
surprise  or  fright  is  also  to  be  called  stuporous." 

Dagonet  says  stupor  results  from  various  causes, 
such  as  exhaustion,  or  emotional  and  intellectual 
factors.  Clinically  it  varies  in  kind  and  degree  ac- 
cording to  the  situation  in  which  it  develops.  When 
it  develops  during  normal  mental  health,  it  disap- 
pears when  its  cause  does.  In  insanity  it  appears 
in  the  course  of  a  psychosis  of  some  duration,  of 


THE  LITERATURE  OF  STUPOR  251 

which  it  seems  a  part,  an  exaggeration  of  some 
symptom  of  the  general  condition.  Evidently  he 
views  stupor  as  a  type  of  reaction :  as  a  more  or  less 
complete  suspension  of  the  operation  of  intellectual 
faculties,  a  more  or  less  sudden  subtraction  of 
nervous  forces.  This  reaction  can  result  from  a 
fright  or  the  memory  of  it,  a  brain  lesion  or  trauma, 
the  action  of  narcotics,  exhausting  fevers,  excessive 
grief,  the  terrors  of  alcoholic  hallucinations,  epilep- 
tic seizures,  profound  anemia  and  nervous  exhaus- 
tion consequent  on  sexual  excess.  He  is  careful  to 
say  that  both  symptoms  and  treatment  vary  with 
the  varied  etiologies. 

He  credits  Pinel  with  being  the  first  to  call  atten- 
tion to  stupor.  This  author  claimed  that  some 
persons  with  extreme  sensibility  could  be  so  upset 
by  any  violent  emotion  as  to  have  their  faculties 
suspended  or  obliterated.  He  noted,  too,  that 
stupors  frequently  terminated  in  manic  phases  of 
20  to  30  days'  duration.  Pinel  also  emphasized  the 
apathy  of  these  cases.  Esquirol  called  stupor 
*' acute  dementia,''  a  term  which  persisted  in  French 
literature  for  a  long  time.  He  described  an  inter- 
esting circular  case  where  alternations  between 
mania  and  t3npical  stupor  took  place.  He  mentions 
too  the  dangerous,  impulsive  tendencies  of  many 
patients.  Georget  emphasized  the  fact  which  Pinel 
had  also  noted,  that  retrospectively  the  stupor  pa- 
tient says  his  mind  was  a  blank  during  the  attack. 
In  1835  Etoc-Demazy  published  on  the  subject.  He 
regarded  stupor  not  as  a  separate  form  of  insanity 


252  BENIGN  STUPORS 

but  a  complication  ensuing  on  monomania  or  mania. 
He  recognized  the  partial  as  well  as  complete  stupor. 
He  thought  the  condition  was  due  to  cerebral 
edema,  as  did  other  writers  of  that  period.  Dago- 
net  remarks  about  this  last — a  lesson  not  learned  in 
fifty  years  by  the  profession — that  demonstrable 
edema  does  not  produce  the  typical  symptoms  of 
stupor.  Baillarger  in  1843  (Annales  Medico-psycho- 
logiques)  was  the  first  whose  ambition  to  simplify 
psychiatric  types  led  to  denial  of  a  separate  kind 
of  reaction.  He  claimed  that  stupor  was  not  a  form 
of  insanity  but  an  extension  of  a  ^*delire  melan- 
cholique. ' '  As  Dagonet  remarks,  every  symptom  by 
which  he  characterizes  stupor  is  a  psychiatric  symp- 
tom and  insanity  can  consist  just  as  well  in  the 
dimunition  as  the  perversion  or  exaltation  of  normal 
faculties.  Some  of  Baillarger 's  cases  had  false 
ideas,  some  apparently  none  at  all.  Dagonet  thinks 
this  justifies  two  types,  one  a  dream-like  state  and 
another  where  no  ideas  are  present,  although  he 
admits  one  may  be  an  exaggeration  of  the  other. 
Brierre  de  Boismont  (Annales  Medico-psycholog- 
ique,  1851,  p.  442)  compares  these  two  kinds  of 
stupors  to  deep  sleep  when  intelligence  is  completely 
suspended  and  to  sleep  with  dreams.  (These  two 
types  would  correspond  to  our  '^absorbed  mania'* 
and  true  deep  stupor.)  He  urges  strongly  the 
separation  of  stupor  from  melancholia  as  an  entirely 
different  type  of  reaction,  in  this  connection  citing 
the  views  pro  and  con  of  various  authors.    Of  these 


THE  LITERATURE  OF  STUPOR  253 

Delasiauve  is  particularly  cogent  in  discriminating 
stupor  from  melancholia  on  the  grounds  of  the  dif- 
ference of  the  emotional  reactions  and  of  the  intel- 
lectual disorder  and  the  real  paucity  of  thought  in 
the  former  psychosis. 

After  quoting  these  and  other  authors,  Dagonet 
offers  an  explanation  for  the  diversity  of  opinion. 
He  says  that  stupor  following  another  psychosis 
may  retain  some  of  its  symptoms,  so  that  a  mixture 
obtains,  as  often  in  medicine.  He  then  gives  excel- 
lent descriptions  of  three  types:  the  deep  stupor 
with  paralysis  of  the  faculties,  the  cases  that  are 
absorbed  in  false  ideas,  and  ecstatic  cataleptics. 

The  remainder  of  his  paper  is  concerned  with 
cases  and  discussions  about  them.  He  cites  exam- 
ples of  stupor  following  fear  or  other  emotional 
shocks,  following  grave  injuries  such  as  the  loss  of 
a  limb,  following  head  trauma  and  with  typhoid 
fever.  As  to  the  last  he  points  out  that  delirious 
features  are  prominent.  Many  authors  have  as- 
signed sexual  excesses  as  a  cause  of  stupor.  The 
psychosis,  Dagonet  says,  is  not  pure  but  more  a 
mixture  of  hypochondria  and  depression.  Relation- 
ship with  mania  is  next  considered.  He  says  that 
stupor  may  succeed,  alternate  with  or  precede 
mania.  His  cases  seem  mainly  to  have  been  what 
we  call  absorbed  manics  or  manic  stupors.  In  fact, 
he  uses  the  last  term.  The  commonest  introductory 
psychosis,  he  claims,  is  depression,  but  from  his 
brief  case  reports  it  would  seem  that  most  of  his 


254  BENIGN  STUPORS 

patients  were  not  stuporous,  in  the  narrow  sense  of 
the  term,  but  severely  retarded  depressions.  In  fact, 
in  perusing  his  case  material  comprising  '^stupors" 
in  the  course  of  many  types  of  functional  insanity, 
or  as  a  complication  of  epilepsy  or  general  paraly- 
sis, it  is  evident  that  in  practice  he  does  not  follow 
the  discriminative  definitions  of  the  earlier  portion 
of  his  paper.  For  him,  apparently,  patients  who 
are  markedly  inaccessible  to  examination  from 
whatever  cause  are  ''stuporous.'*  He  closes  with 
excellent  remarks  on  physical  and  psychic  treat- 
ment. As  to  prognosis  he  has  nothing  to  say  beyond 
the  opinion  that  most  of  the  cases  recover. 

If  Dagonet  be  accepted  as  summarizing  the  early 
French  work,  we  can  conclude  that  their  generaliza- 
tions were  on  the  whole  quite  sound.  These  were: 
that  stupor  is  an  abnormal  mental  reaction,  usually 
psychogenic  but  often  the  result  of  exhaustion,  that 
it  consists  in  a  paralysis  of  emotion,  will  and  intel- 
ligence; that  the  prognosis  is  usually  good;  that 
mental  stimulation  may  produce  recovery.  What 
remained  to  be  done  after  this  work  was  the  refine- 
ment in  detail  of  these  generalizations,  particularly 
in  respect  to  the  differentiation  of  prognostically 
benign  and  malignant  types.  But  other  Frenchmen 
did  not  take  up  this  work,  apparently,  for  the  bril- 
liant psychopathologists  of  the  next  generations 
attended  to  stupor  only  in  so  far  as  it  was  hysterical. 

An  Englishman,  however,  soon  took  up  the  task, 
adding  more  exactness  to  his  formulations.     New- 


THE  LITEEATURE  OF  STtJPOE  255 

ington  ^  published  his  important  paper  in  1874.  A 
nascent  stage  of  stupor,  he  thinks,  is  a  connnon  re- 
action to  great  exhaustion,  "such  as  hard  mental 
work,  prolonged  or  acute  illness,  dissipation,  etc.'' 
Such  conditions,  like  the  grave  psychotic  forms,  he 
regarded  as  due  to  physical  exhaustion  of  the  brain 
cells,  but,  since  he  thought  psychic  stress  could  pro- 
duce this  exhaustion,  this  "organic"  view  did  not 
bias  his  general  formulations.  He  makes  a  division 
into  two  stupors :  Anergic  Stupor  and  Delusional 
Stupor.  The  former  may  be  primary,  being  gener- 
ally caused  by  a  sudden  intense  shock  (Esquirol's 
"Acute  Dementia"),  or  secondary  (a)  to  convul- 
sions of  any  kind,  (b)  to  mania  in  women,  (c)  to  any 
other  prolonged  nervous  exhaustion.  The  delusional 
form  results  from  (a)  intense  melancholia,  (b)  from 
general  paralysis  in  which  it  may  be  intercurrent, 
(c)  from  epileptic  seizures.  When  one  examines  his 
points  of  difference  between  these  two  types,  it  be- 
comes clear  that  Newington  really  gave  an  excellent 
differentiation  of  benign  and  malignant  stupor — in 
fact,  it  is  the  only  serious  attempt  at  such  discrimi- 
nation prior  to  this  present  work.  What  is  more 
remarkable  is  the  fact  that,  although  he  clearly  saw 
the  clinical  differences,  he  failed  to  see  that  the  two 
types  differed  prognostically.  His  description  is 
given  in  a  table  sufficiently  concise  to  justify  its 
quotation  in  extenso. 

^  Newington,  H.  Hayes :  '  *  Some  Observations  on  Different  Forms 
of  Stupor,  and  on  Its  Occurrence  after  Acute  Mania  in  Females." 
Journal  of  Mental  Science,  Vol.  XX,  1874,  p.  372. 


256 


BENIGN  STUPORS 


ANERGIC  STUPOR 


DELUSIONAL  STUPOR 


Etiology — Hereditary    and    in-      Hereditary, 
dividual   liability   to   sudden 
loss  of  vis  nervosa. 


Onset — ^Rapid. 


Usually  insidious,  may  be  al- 
most instantaneous. 


Symptoms  —  Intellect     greatly      Conduct  shows  reasoning  pow- 
impaired.  er. 


Memory — Seems    to    be    swept 
away  as  far  as  possible. 


Found  after  recovery  to  have 
been  preserved  to  a  great 
extent. 


Emotional     Capacity — Nil     or      Evidence  of  grief,  fear,  etc.,  in 


almost  so.  Tears  frequent 
but  due  to  relaxation  or 
sphincter  muscles.  Features 
relaxed,  eyes  vacant  and  not 
constantly  fixed. 


facial  expressions  and  wring- 
ing and  clasping  of  hands. 
Tears  rare.  Great  contrac- 
tion of  features  [grimac- 
ing?]. Eyes  fixed  on  one 
point,  usually  upwards  or 
downwards,  or  else  obsti- 
nately closed. 


Volition — Almost  absent. 


Motor  System — Weak  and  un- 
certain. Patient  has  to  be 
led  about  and  if  placed  on  a 
seat  or  in  some  position  does 
not  move.  ("Cataleptoid" 
condition.) 


Frequently  great  stubborn- 
ness, refusal  to  do  what  is 
wanted.  On  the  other  hand, 
intense  determination  in  fol- 
lowing out  own  plan. 

But  little  interfered  with,  in- 
dependently of  sheer  as- 
thenia, produced  by  patient's 
conduct.  May  stand  behind 
door  or  kneel  on  floor  in  con- 
strained position  even  for 
days. 


THE  LITERATURE  OF  STUPOR 


257 


ANERGIC  STUPOR 

Sensory  System^ -^  ,,     ,  ,, 

Reflex  System    j 


Pupils — Dilated. 
Sleep — Generally   good. 

General  h  o  dily  condition — 
Emaciation,  sometimes  ex- 
treme, usually  rapid,  with 
rapid  recovery  of  flesh. 
Often  not  much  loss  of 
weight,  though  whole  tone  is 
lowered. 

Vascular  System — Pulse  slow, 
sometimes  almost  impercep- 
tible. Cyanotic  appearance, 
edema  and  iciness  of  ex- 
tremities. Great  decrease  of 
vitality  in  peripheral  struc- 
tures, as  shown  by  asthenic 
eruptions  and  production  of 
vermin. 

Digestive  System  —  Tongue 
clean  or  if  furred  it  is  moist. 
Appetite  apathetic,  bowels 
not  irregular,  but  habits 
very  dirty. 


DELUSIONAL  STUPOR 

Ditto.  There  seems  to  be  a 
much  greater  ability  to  bear 
severe  pain. 

Tendency  to  contraction. 

Intense  sleeplessness. 

Affected  pari  passu  with  men- 
tal state  and  seems  governed 
by  it. 


Pulse  weak  and  often  quick 
and  thready.  Complexion 
anemic  and  sallow.  The 
other  appearances  may  be 
present  but  come  on  later 
and  are  less  marked. 


Tongue  dry,  small  and  furred. 
Refusal  of  food.  Great  con- 
stipation. Dirtiness  of  hab- 
its rare. 


If  one  compares  these  data  with  those  given  in 
the  chapter  on  Malignant  Stupors,  it  is  seen  that  in 
the  main  Newington  has  made  the  same  discrimina- 
tion as  we  have.  He  is  certainly  wrong  in  denying 
*' negativism''  to  his  anergic  type.  Probahly,  too, 
he    attempts    too    fine    a    distinction   between   the 


258  BENIGN  STUPORS 

physical  symptoms  of  the  two  groups.  His  conclu- 
sions are  interesting :  that  in  the  anergic  cases  there 
is  an  absence  of  cerebration,  while  amongst  the  delu- 
sional there  is  an  abnormal  presence  of  intense  but 
perverted  cerebration.  This  is  not  unlike  our  own 
view.  He  thinks  the  difference  in  memory  is  the 
most  important  differential  point.  Sex  is  important 
in  determining  the  nature  of  the  stupor,  for  he  found 
the  anergic  type  following  mania  in  females  only. 
He  observed  such  an  end  to  manic  attacks  in  6  out 
of  36  cases.  All  his  cases  were  under  30  and  he  re- 
gards the  prognosis  as  good  on  the  whole.  As  to 
treatment  he  emphasizes  the  necessity  for  ^^  moral 
pressure '^  as  a  stimulus  and  cites  a  case  of  rapid 
improvement  after  a  change  of  scene. 

Since  1874  very  little  advance  has  been  made  by 
British  psychiatrists,  as  seen  by  a  perusal  of  Clous- 
ton's  ®  summary  in  1904.  He  regards  sex  exhaustion 
as  a  highly  frequent  cause,  although  Dagonet  had 
shown  32  years  before  that  sex  abuse  does  not  pro- 
duce a  true  stupor.  He  thinks  stupor  usually  follows 
depression  or  mania  and  says  that  '^  the  ^  Confusional 
Insanity'  of  German  and  American  authors  is  just 
a  lesser  degree  of  stupor."  Omitting  his  stupors  in 
general  paralysis  and  epilepsy  he  makes  three  clini- 
cal divisions :  melancholic  or  conscious  stupor,  which 
is  not  a  product  of  delusions,  although  delusions  of 
death  or  great  wickedness  may  be  present,  im- 
pulsiveness and  fits  may  be  observed;  anergic  or 

^Clouston:    '^  Mental  Disea&es.''    J.  &>  A.  Churchill,  1904. 


THE  LITERATURE  OF  STUPOR  259 

unconscious  stupor,  which  corresponds  roughly  to 
our  deep,  benigii  stupor ;  and  secondary  stupor  after 
acute  mental  disease,  which  resembles  our  partial 
stupor.  He  warns  against  a  rash  diagnosis  of  de- 
mentia in  this  last  group.  His  views  on  the  impor- 
tance of  mental  causation  and  the  relation  to  manic- 
depressive  insanity  may  be  gathered  from  these 
sentences :  ''The  condition  of  the  mental  portion  of 
the  convolutions  in  stupor  is  probably  analogous  to 
the  stupidity  of  a  nervous  child  when  terrified  or 
bullied.''  ''Stupor  is  frequently  one  of  the  stages 
of  alternating  insanity  following  the  exalted  condi- 
tion. It  is  more  apt  to  occur  in  those  where  the 
exalted  period  is  acutely  maniacal.  The  stupor  is 
usually  melancholic  in  form. ' '  Since  he  claims  that 
the  anergic  is  a  "very  curable  form  of  mental  dis- 
ease," while  only  50%  of  the  melancholic  cases  re- 
cover, it  seems  clear  that  this  division  is  not 
prognostically  final.  The  ' '  melancholic ' '  is  evidently 
Newington's  "delusional"  without  his  more  accu- 
rate discrimination  of  symptoms. 

From  the  standpoint  of  accurate  description  the 
opinion  may  be  ventured  that  there  is  a  gap  in  the 
literature  from  the  early  French  writers  and  New- 
ington  up  to  the  paper  by  Kirby,  which  has  been  dis- 
cussed in  the  first  chapter.  This  gap  is  filled  by 
literature  of  the  German  schools  and  their  adherents 
in  other  countries.  German  psychiatry  has  been 
concerned  mainly  with  classification  or  the  elaborate 
examination  of  certain  symptoms.  Inevitably  such 
a  program  militates  against  detached  objective  clini- 


260  BENIGN  STUPORS 

cal  description.  It  is  hard  to  record  symptoms  that 
interfere  with  classification.  German  psychiatry  has 
tended  to  make  the  insane  patient  a  type  rather 
than  an  individual.  Hence  the  gap  in  the  descriptive 
literature  of  stupor. 

The  necessity  of  establishing  the  possibility  of 
some  stupors  having  a  good  prognosis  has  arisen 
from  Kraepelin's  work.  He  can  rightly  be  viewed 
as  the  father  of  modern  psychiatry  because  he  intro- 
duced a  classification  based  on  syndromes  and 
taught  us  to  recognize  these  disease  groups  in  their 
early  stages.  Inevitably  with  such  an  ambitious 
scheme  as  the  pigeon-holing  of  aU  psychotic  phe- 
nomena some  mistakes  were  made.  Most  of  these 
appear  in  the  border  zone  between  dementia  praecox 
and  manic-depressive  insanity.  The  latter  group 
being  narrowly  defined,  the  former  had  to  be  a  waste 
basket  containing  whatever  did  not  seem  to  be  a 
purely  emotional  reaction.  Clinical  experience  soon 
proved  that  many  cases  which,  according  to  Kraepe- 
lin^s  formulae,  were  in  the  dementia  praecox  group, 
recovered.  Adolf  Meyer  was  one  of  the  first  to  pro- 
test and  offered  categories  of  **  Allied  to  Manic- 
Depressive  Insanity''  or  ^* Allied  to  Dementia  Prae- 
cox,"  as  tentative  diagnostic  classifications  to  in- 
clude the  doubtful  cases.       • 

Difficulties  with  stupor  furnish  an  excellent  ex- 
ample of  the  confusion  which  results  from  the  adop- 
tion of  rigid  terminology.  The  earlier  psychiatrists 
were  free  to  regard  a  patient  in  stupor  as  capable 
of  recovery  as  well  as  deterioration.    When  Kahl- 


THE  LITERATURE  OF  STUPOR  261 

baum  included  stupor  with  "Catatonia,"  the  situa- 
tion was  not. changed,  for  he  did  not  claim  a  hopeless 
prognosis  for  this  group.  But  when  Kraepelin  made 
catatonia  a  subdivision  of  dementia  prsecox,  all 
stupors  (except  obvious  phases  of  manic-depressive 
insanity)  had  to  be  hysterical  or  malignant.  Faced 
with  this  dilemma  psychiatrists  have  either  called 
recoveries  ^* remissions"  or,  like  E.  Meyer,  claimed 
that  one-fifth  or  one-fourth  of  catatonics  really  get 
well. 

As  a  matter  of  fact  it  seems  clear  that  stupor  is  a 
psych obiological  reaction  that  can  occur  in  settings 
of  quite  varied  clinical  conditions.  It  is  not  iieces- 
sary  to  detail  publications  describing  stupors  in 
hysteria,  epilepsy,  dementia  prsecox  or  in  the  organic 
psychoses.  It  may  be  of  interest,  however,  to  cite 
some  examples  of  acute,  benign  stupors  and  the  dis- 
cussion of  them  which  appear  in  the  literature  of 
recent  years. 

An  important  group  is  that  of  stupors  occurring 
as  prison  psychoses.  Stern  ^  mentions  that  acute 
stupors  are  found  in  this  group.  Wilmanns  ^  ex- 
amined the  records  for  five  years  in  a  prison  and 
discovered  that  there  were  two  forms  of  psychotic 
reaction,  a  paranoid  and  a  stupor  type.  It  is  inter- 
esting psychologically  that  the  former  appeared 
largely   among  prisoners   in   solitary   confinement, 

*  Stern :  *  *  Ueber  die  akuten  Situations-psychosen  der  Kriminellen. ' ' 
Abstracted,  Zeitschr.  f.  d.  ges,  Neurol,  u.  PsycMatrie,  Eeferate  Bd. 
V,  S.  554. 

•Wilmanns,  K. :  ''Statische  Untersuchungen  iiber  Gefangnisspsy- 
chosen. "     Allgemeime  Zeitschr.  f.  PsycMatrie,  Bd.  LXVII,  S.  847. 


262  BENIGN  STUPORS 

while  the  stupors  developed  preponderantly  among 
those  who  were  not  isolated.  The  stupors  recovered 
more  quickly.  He  describes  the  psychosis  thus: 
The  prisoner  becomes  rather  suddenly  excited,  de- 
structive and  assaultive;  then  soon  passes  into  an 
inactive  state,  where  he  lies  in  bed,  mute,  with  open 
expressionless  eyes.  He  is  clean,  however;  eats 
spontaneously  and  attends  to  his  own  hygienic 
needs.  Some  cases  are  roused  by  transport  from 
the  jail  to  the  hospital  but  sink  into  lethargy  again 
when  they  reach  their  beds.  Physically,  they  show 
disturbances  of  sensation  which  vary  from  analgesia 
to  hypesthesia.  There  are  a  rapid  pulse,  posi- 
tive Eomberg  sign,  exaggerated  reflexes,  fibrillary 
twitching  of  the  tongue  and  tremor  of  the  hands. 
Eecovery  takes  place  gradually.  They  begin  to 
react  to  physical  stimuli  and  to  answer  questions, 
although  still  inhibited,  until  consciousness  is  quite 
clear.  When  speech  begins,  it  is  found  that  they  are 
usually  disoriented  for  place  and  time  as  the  result 
of  an  amnesia  which  sets  in  sharply  with  the  excite- 
ment. This  memory  defect  gradually  improves  pari 
passu  with  the  other  symptoms. 

Two  attacks  in  the  same  prisoner  of  what  seem  to 
have  been  typical  stupor  are  reported  by  Kutner  ^ 
and  Chotzen.'^  The  patient  was  a  recidivist  of  un- 
stable mental  make-up.    At  the  age  of  34  he  was  sent 

^  Kutner :  '  '■  Ueber  katatoniseher  Zustandsbilder  bei  Degenerierten. ' ' 
Allgemeine  Zeitschr.  f.  PsycMatrie,  Bd.  LXVII,  S.  375. 

■^  Chotzen :  ' '  Fall  von  degenerativem,  Stupor. ' '  Abstracted, 
Zeitschr.  f.  d.  ges,  JsPeur-  v,  Fsychiatrie,  Eeferate,  Bd.  VI,  S.  1077. 


THE  LITEEATURE  OF  STUPOR  263 

to  prison  for  three  years.  Shortly  after  confinement 
began,  he  became  stuporous,  being  mute  and  nega- 
tivistic,  soiling,  refusing  food  and  showing  stereo- 
typy- C)n  being  shifted  to  another  institution  he  ap- 
peared suddenly  much  better,  although  he  remained 
apathetic  and  dull  for  some  months.  A  striking 
feature  was  a  complete  amnesia,  not  merely  for  the 
stupor  but  also  for  his  trial  and  entrance  to  the 
prison.  At  the  age  of  42,  he  was  again  incarcerated. 
A  practically  identical  picture  again  developed,  with 
recovery  when  his  environment  was  changed,  and 
with  a  similar  amnesia.  Eecovery  seemed  to  be 
complete  and  there  were  no  hysterical  stigmata. 
The  interesting  features  of  this  case  are  that  a 
typical  stupor  seems  to  have  been  precipitated  by 
imprisonment,  while  the  retroactive  amnesia  cover- 
ing a  painful  period  of  the  patient's  life  reminds  one 
of  hysteria. 

A  case  which  is  more  difficult  to  interpret  is  re- 
ported briefly  by  Seelig.^  A  man  of  20  with  bad 
inheritance  tried  to  steal  100  marks.  When  sent  to 
jail  he  became  ill  shortly  before  his  trial  was  due 
and  was  sent  to  a  hospital.  There  he  seemed  anx- 
ious, was  shy,  and  gave  slow  answers,  with  initial 
lip  motions  and  had  to  be  urged  to  take  hold  of 
objects.  All  this  sounds  more  like  a  pure  depression 
than  a  stupor.  But  he  also  had  paralogia.  This 
might  make  one  think  of  a  Ganser  reaction  on  the 
background  of  depression.     S.,  however,  calls  it  an 

*See]ig:     ' '  Psychiatrischer    Verein    in    Berlin,     1904."      Neurol. 
Centralbl,  1904,  S.  421. 


264  BENIGN  STUPORS 

hysterical  stupor,  although  he  agreed  with  Moeli 
that  it  was  hard  to  dither entiate  from  a  catatonic 
state. 

Lowenstein  ^  reports  an  interesting  case  of  a 
degenere  who  had  had  hysterical  attacks.  He  sud- 
denly developed  stupor  symptoms,  which  lasted  with 
interruptions  for  nearly  two  years.  After  recovery 
and  during  the  interruptions  the  patient  explained 
his  mutism,  refusal  to  swallow,  his  filthiness  and 
general  negativism  as  all  occasioned  by  delusions. 
He  was  commanded  by  God  to  act  thus,  the  attend- 
ants were  devils,  and  so  on.  He  spoke,  too,  of  being 
under  hypnotic  influence.  In  addition  there  were 
other  delusions  such  as  that  he  had  killed  his 
brother.  The  attack  came  on  with  the  belief  that  he 
was  going  to  die,  otherwise  none  of  the  ideas  were 
typical  of  the  stupors  we  have  studied.  Another 
incongruous  symptom  was  that  he  did  not  seem  to 
be  really  apathetic,  he  reacted  constantly  to  the  en- 
vironment. The  author  comments  on  the  absence  of 
senseless  motor  phenomena,  such  as  would  be  ex- 
pected in  a  ''catatonic."  His  complete  memory  of 
the  psychosis  also  speaks  against  the  usual  form  of 
stupor.  It  seems  possible  that  this  psychosis  was 
neither  hysterical  nor  a  benign  stupor  in  our  sense, 
but,  rather,  an  acute  schizophrenic  reaction  such  as 
one  occasionally  sees.  From  the  account  which  Low- 
enstein gives,  one  gathers  that  the  patient  was  ab- 
sorbed in  a  wealth  of  imaginations. 

^  Lowenstein :    ' '  Beitrag  zur  Diff erentialdiagnose   des  katatonische 
u.  hysterische  Stupors."     Allg.  Zeitschr.  f.  FsycJiiatrie,  Bd.  LXV. 


THE  LITERATURE  OF  STUPOR  265 

Gregor  ^°  tells  of  a  stupor  which  is  unusual  in  that 
it  consisted  only  of  symptoms  connected  with  inac- 
tivity, which  did  not  affect  the  intellectual  processes. 
The  patient  was  a  rubber  worker  who  suddenly  de- 
veloped a  depression  with  self -accusation  and 
convulsions.  She  was  soon  admitted  to  a  clinic  and  • 
then  showed  mutism  and  catalepsy.  Later  she  be- 
came totally  immobile  with  no  apparent  psychic 
reactions,  and  soiled.  Gregor  studied  pulse,  respira- 
tion and  respiratory  volume  in  their  reflex  mani- 
festations and  found  nothing  unusual.  Next  he 
tried  to  discover  if  there  were  voluntary  alterations 
in  respiration.  He  discovered  that  the  respiratory 
curve  could  be  changed  by  calling  out  words  to  her, 
by  odors  associated  with  suggestions,  menaces,  etc. 
[This  is  suggestive  of  the  dissociation  of  affect, 
which  we  have  discussed.]  After  two  months  she 
recovered,  ivith  complete  recollection  of  the  stupor 
period.  It  was  then  proven  that  the  absence  of 
reactions  was  not  the  same  as  the  lack  of  perception 
of  stimuli. 

Froederstrom  ^^  reports  a  case  that  suggests  hys- 
teria, where  the  stupor  lasted  for  32  years.  A  girl 
at  the  age  of  14  fell  on  the  ice,  had  a  headache,  went 
to  bed  and  stayed  there  for  32  years.    She  lay  there 

"  Gregor :  ' '  tJber  die  Diagnose  psyehischer  Prozesse  im  Stupor. ' ' 
Leipzig  Meeting,  1907.  Reported  in  Neurol.  Centralhl.,  1907.  S. 
1083. 

"Froederstrom:  "La  Dormeuse  d'Okno.  32  ans  de  Stupeur, 
Guerison  complete.  Nouvelles  Iconographies  de  la  Salpetriere, ' ' 
1912,  No.  3.  Reviewed  by  E.  Bloch,  Neur.  Centralhl.,  1913,  S.  852, 
and  by  Forster,  Zeitsch.  f.  d.  ges.  Neur.  u.  PsycMatrie,  Referate, 
Bd.  VI,  S.  510. 


266  BENIGN  STUPORS 

immobile,  occasionally  spoke  briefly  and  took  nour- 
ishment, when  it  was  put  at  a  dehnite  place  at  the 
edge  of  the  bed.  At  hrst  (according  to  a  late  state- 
ment of  her  brothers)  this  consisted  only  of  water 
but  was  soon  changed  to  two  glasses  of  milk  a  day. 
After  being  in  this  state  for  ten  years  she  was  placed 
in  a  hospital  for  two  weeks,  where  she  was  mute, 
did  not  react  to  pin  pricks  and  had  to  be  fed.  It 
seems  that  at  home  she  secretly  looked  after  herself, 
for  she  kept  her  hair  and  nails  in  condition.  Some- 
times she  sat  up  and  stared  at  the  ceiling. 

After  attending  to  the  patient  for  30  years,  her 
mother  died.  The  patient  cried  for  several  days 
when  told  of  it,  and  after  this  she  took  nourishment 
of  her  own  accord.  Two  years  later  a  brother  died. 
Again  she  cried  on  hearing  the  news.  Her  father, 
who  looked  after  her  when  the  mother  was  dead,  also 
died.  Then  a  governess  came  into  the  home,  who 
noticed  that  furniture  was  moved  about  when  she 
was  alone. 

At  the  age  of  46  she  suddenly  woke  up  and  asked 
at  once  for  her  mother.  She  claimed  total  amnesia 
for  the  period  of  her  stupor,  including  the. stay  at 
the  hospital.  She  could  summon  memories  of  her 
childhood,  however.  Her  brothers  she  did  not  rec- 
ognize and  said,  ^^They  must  be  small."  She  re- 
called the  fall  on  the  ice  and  coming  home  with 
headache,  toothache  and  pain  in  the  back.  Her  gen- 
eral knowledge  was  limited  but  she  could  read  and 
write.  Her  expression  and  appearance  was  that  of 
a  young  person,  only  her  atrophic  breasts  and  the 


THE  LITERATURE  OF  STUPOR  267 

fat  on  her  buttocks  betraying  her  age.  She  had  been 
well  for  four  years  at  the  time  the  report  was  made. 

He  thinks  that  a  certain  tendency  to  exaggeration 
and  simulation  speak  for  hysteria.  We  would  be 
more  inclined  to  view  the  fact  that  she  looked  after 
herself  in  spite  of  complete  amnesia  as  evidence  of 
hysteria. 

Another  protracted  case  suggestive  of  hysteria  is 
that  reported  by  Gadelius.^^  The  patient  was  a 
tailor,  32  years  old,  who  had  always  been  rather 
taciturn  and  slow.  A  year  before  admission  he  began 
to  have  ideas  of  persecution  and  to  shun  people.  Then 
he  developed  a  stereotyped  response,  "It  is  nice 
weather,"  whenever  he  was  addressed.  A  month 
before  admission  inactivity  set  in.  He  would  sit 
immobile  in  his  chair  with  closed  eyes  and  relaxed 
face ;  he  resisted  when  an  attempt  was  made  to  put 
him  to  bed.    His  color  was  pale. 

He  was  taken  to  hospital  on  November  1,  1882, 
where  he  was  observed  to  be  immobile  and  to  have 
little  reaction  to  pin  pricks.  When  a  limb  was  raised, 
it  fell  limply.  However,  he  would  leave  bed  to  go  to 
the  toilet.  Tube-feeding  became  necessary,  but  when 
the  tube  was  inserted  in  his  nose,  he  woke  up.  He 
then  showed  an  amnesia  not  merely  for  his  illness 
but  for  his  whole  life :  he  did  not  know  his  father, 
that  he  was  married  or  that  he  had  a  mother.    To- 

"  Gadelius :  ' '  Ett  ovanligt  fall  af  stupor  med  nara  9-arig  oaf bruten 
tvangsmatning;  uppvaknande;  total  amnesi;  helsa'^  (Hygiea,  1894, 
LVI.,  Part  2,  No  10,  p.  355).  Abstracted  by  Walker  Berger,  Neurol. 
Centralbl,  1895,  S.  186. 


268  BENIGN  STUPORS 

wards  the  end  of  November,  lie  became  limp  again 
and  answered,  '^I  don't  know''  to  most  questions. 
In  December,  however,  he  improved  again  and  for 
a  few  months  these  variations  occurred.  From 
April,  1883,  to  May,  1886,  he  was  in  deep  stupor, 
almost  absolutely  immobile  and  close  to  being  com- 
pletely anesthetic  even  with  strong  Faradic  cur- 
rents. Towards  the  end  of  this  period  he  walked 
about  whenever  he  thought  he  was  not  watched.  He 
was  very  cautious  about  this  and  became  motionless 
any  time  he  became  aware  of  observation.  (Gadelius 
thinks  this  was  not  simulation  but  the  expression  of 
an  automatism  on  the  basis  of  a  vague  fixed  idea.) 

This  condition  persisted  apparently  for  five  years 
more,  by  the  end  of  which  time  the  anesthesia  had 
turned  into  a  hyperesthesia.  A  year  later  he  began 
to  eat.  It  was  now  found  that  he  had  an  amnesia 
for  his  illness  and  former  life,  so  that  he  did  not 
even  recognize  a  needle  or  pair  of  scissors.  He  knew 
that  he  was  born  in  the  month  of  February  and  re- 
tained some  facility  in  calculation,  in  speech,  walk- 
ing and  usual  motions.  Then  he  regained  all  his 
memories  and  resumed  his  trade  as  tailor.  He  was 
discharged  in  June,  1893,  nearly  eleven  years  after 
admission. 

It  seems  safe  to  say  that  elements  at  least  of  hys- 
teria appear  in  this  history,  such  as  the  profound 
retroactive  amnesia  and  appearance  of  simulation 
in  the  conduct  of  the  patient.  Accurate  and  rapid 
grasp  of  the  environment  is  necessary  for  such  a 
watch  as  he  kept  on  the  eye  of  his  attendants.    Men- 


THE  LITERATURE  OF  STUPOR  269 

tal  acuity  of  this  grade  combined  with  amnesia  looks 
more  like  an  hysterical  than  a  manic-depressive 
process. 

Leroy^^  describes  a  case  much  like  ours  which  is 
interesting  from  a  therapeutic  standpoint.  The  pa- 
tient was  a  woman  who  passed  from  a  severe  depres- 
sion with  hallucinations  and  anxiety  into  a  long 
stupor,  from  which  she  recovered  completely.  There 
was  no  negativism  and  no  atf  ect,  although  the  latter 
appeared  so  soon  as  contact  began  to  be  established. 
When  well  she  had  a  complete  amnesia  for  the  onset 
of  the  psychosis.  Leroy  attributed  the  recovery,  in 
part  at  least,  to  the  thorough  attention  given  the 
patient.  Kraepelinian  rigidity  is  seen,  however,  in 
the  author's  refusal  to  regard  the  case  as  "circular" 
because  of  the  lack  of  all  cyclic  symptoms.  He  takes 
refuge  in  the  meaningless  label  ''Mental  Confu- 
sion." 

An  important  group  of  cases  is  that  of  the  stupors 
occurring  during  warfare.  Considering  stupor  as 
a  withdrawal  reaction,  it  is  surprising  there  were  so 
few  of  them,  although  partial  stupor  reactions  as 
functional  perpetuation  of  concussion  were  very 
common.  The  editor  saw  several  typical  cases  in 
young  children  in  London  who  passed  into  long 
''sleeps"  apparently  as  a  result  of  the  air  raids. 

"  L#eroy :  ' '  Un  cas  de  stupeur,  gueri  au  bout  de  deux  ans  et 
demi."  Bull,  de  la  Soc.  Clm.  de  Med.  Ment.,  Ill,  276,  1910.  Ab- 
stracted in  Zeitschr.  f.  d.  ges.  Neurol,  u.  Psychiatrie,  Eeferate,  Bd. 
II,  S.  495. 


270  BENIGN  STUPORS 

Myers  ^^  lias  given  us  the  best  account  of  stupors  in 
actual  warfare.  A  typical  case  was  that  of  a  man 
who  was  found  in  a  dazed  condition  and  difficult  to 
arouse.  He  could  give  little  information  about  him- 
self, could  neither  read  nor  write  and  never  spoke 
voluntarily.  A  week  later  his  speech  was  still  lim- 
ited and  labored  and  no  account  of  recent  events 
could  be  obtained  from  him.  Under  hypnosis  he  was 
induced  to  talk  of  the  accident  which  had  precipi- 
tated this  disorder.  He  became  excited  in  telling 
his  story,  evidently  visualizing  many  of  the  events. 
In  several  successive  seances,  more  data  were  ob- 
tained and  a  cure  effected.  Myers  points  out  that 
in  all  his  cases  there  was  a  mental  condition  which 
varied  from  slight  depression  to  actual  stupor,  all 
had  amnesias  of  variable  extent  and  all  had  head- 
aches. The  mental  content  seemed  to  be  confined  to 
thoughts  of  bombardment,  with  a  tendency  for  the 
mind  always  to  wander  to  this  topic.  The  author 
thinks  that  pain  is  a  guardian  protecting  the  patient 
from  too  distressing  thoughts.  An  effort  to  speak 
would  cause  pain  in  the  throat  of  a  case  of  mutism 
and,  sometimes,  when  a  distressing  memory  was 
sought  after  under  hypnosis,  physical  pain  would 
wake  the  sleeper.  His  view  is  that  pains  tend  to 
preserve  the  mutism  and  amnesia,  so  that  there  are 
^ inhibitory  processes''  causing  the  stupor,  which 
prevent  the  patient  from  further  suffering.    He  does 

"Myers,  Charles  S.:  ''Contributions  to  the  Study  of  Shell  Shock." 
Lancet,  January  8,  1916,  pp.  65-69.  Lancet,  September  6,  1916,  pp. 
461-467. 


THE  LITERATURE  OF  STUPOR  271 

not  find  either  in  theory  or  experience  reason  to 
believe  that  these  conditions  are  the  result  of  either 
suggestion  or  "fixed  ideas/'  He  thinks  it  natural 
that  the  last  symptom  of  the  stupor  to  disappear 
should  be  mutism,  as  speech  and  vision  are  the 
prime  factors  in  communicating  with  environment. 
[As  has  been  noted  frequently  in  this  book,  mutism 
is  a  common  residual  symptom  of  the  benign 
stupor.]  Myers  believes  that  in  nearly  every  in- 
stance mutism  follows  stupor  and  is  merely  an  at- 
tenuation of  the  latter  process.  When  deafness  is 
associated  with  mutism,  he  thinks  it  is  often  due 
merely  to  the  inattention  of  the  stuporous  state. 

In  this  connection  we  should  mention  that  Gucci  ^^ 
points  out  that  stupor  patients  with  mutism  of  long 
duration  may,  when  requested,  read  fluently  and 
then  relapse  again  into  complete  unreactiveness 
towards  auditory  impressions.  This,  we  would  say, 
is  probably  an  example  of  a  more  or  less  automatic 
intellectual  operation  occurring  when  the  patient  is 
sufficiently  stimulated,  although  he  cannot  be  raised 
to  the  point  of  spontaneous  verbal  productivity. 

As  these  scattered  reports  about  benign  stupors 
are  so  unsatisfactory,  one  naturally  turns  to  text- 
books. Little  more  appears  in  them.  Kraepelin 
treats  stupors  occurring  in  manic-depressive  insan- 
ity as  falling  into  two  groups,  the  depressive  and 

*°  Gucci,  R. :  ' '  Sopra  una  particolarita  del  mutismo  per  stupore 
communicazione  preventive.''  Archivo  italiano  per  le  malattie 
nervofie,  3889,  XXVI,  69-108.  Eeviewed  in  Neurol.  Centralbl,  1889, 
S.  659. 


272  BENIGN  STUPORS 

manic.  The  former  seems  to  be  nearer  to  our  cases, 
judging  by  the  statements  in  his  rather  sketchy  ac- 
count. He  regards  stupor  as  being  the  most  extreme 
degree  of  depressive  retardation.  [This  possibility 
has  been  discussed  in  the  chapter  on  Affect.]  His 
description  seems  perhaps  to  include  cases  which  we 
would  regard  as  perplexity  states  or  absorbed 
manias.  Activity  is  reduced,  they  lie  in  bed  mute, 
do  not  answer,  may  retract  shyly  at  any  approach, 
but  on  the  other  hand  may  not  ward  off  pin  pricks. 
Sometimes  there  is  catalepsy  and  lack  of  will,  again 
there  may  be  aimless  resistance  to  external  interfer- 
ence. They  hold  anything  put  into  their  hands, 
turning  it  slowly  as  if  ignorant  of  how  to  get  rid  of 
it.  They  may  sit  helpless  before  food  or  may  allow 
spoon-feeding.  Not  rarely  they  are  unclean.  As  to 
the  mental  content,  he  says  they  sometimes  utter  a 
few  words,  which  give  an  insight  into  confused  delu- 
sions that  they  are  out  of  the  world,  that  their  brains 
are  split,  that  they  are  talked  about,  or  that  some- 
thing is  going  on  in  the  lower  part  of  the  body.  The 
affect  is  indefinite  except  for  a  certain  bewilderment 
about  their  thoughts  and  an  anxious  uncertainty  to- 
wards external  interference.  Intellectual  processes 
suffer.  They  are  disoriented  and  do  not  seem  to 
understand  the  questions  put  to  them.  An  answer 
'^That  is  too  complicated ' '  may  be  made  to  some 
simple  command.  Kraepelin  thinks  that  the  disorder 
is  sometimes  more  in  the  realm  of  the  will  than  of 
thinking,  for  one  patient  could  do  a  complicated  cal- 
culation in  the  same  time  as  a  simple  addition.  After 


THE  LITERATURE  OF  STUPOR  273 

recovery  the  memory  for  the  period  of  the  psychosis 
is  poor  and  quite  gone  for  parts  of  it.  Occasionally 
there  may  be  bursts  of  excitement,  when  they  leave 
the  bed;  they  may  scold  in  a  confused  way  or  sing  a 
popular  song. 

His  manic  stupor  is  a  ''mixed  condition,"  a  com- 
bination of  retardation  with  elated  mood.  The  con- 
dition is  different  from  the  depressive  stupor  in  that 
activity  is  more  frequent,  either  in  constant  fum- 
bling with  the  bed  clothes  or  in  spasmodic  scolding, 
joking,  playing  of  pranks,  assaultiveness,  erotic 
behavior  or  decoration.  The  affect  is  usually  ap- 
parent in  surly  expression  or  happy,  or  erotic,  de- 
meanor. They  are  usually  fairly  clear  and  oriented 
and  often  with  good  memory  for  the  attack  but  with 
evasive  explanations  for  their  symptoms.  One  can- 
not make  any  classification  of  the  ideas  he  quotes, 
but  it  is  apparent  from  all  his  description  that  the 
minds  of  these  "manic  stupors"  are  not  a  blank  but 
rather  that  there  is  a  fairly  full  mental  content. 

Wernicke,  unhampered  by  classifications  of  cata- 
tonia and  manic-depressive  insanity  with  inelastic 
boundaries,  calls  all  stupor  reactions  akinetic  psy- 
choses w^ith  varying  prognosis.  He  does  not  make 
Kraepelin's  mistake  of  confusing  the  apathy  of 
stupor  with  the  retardation  of  depression,  stating 
distinctly  that  the  processes  are  different. 

Bleuler  also  has  grasped  this  discrimination.  He 
points  out  that  the  thinking  disorder  in  what  he 
terms  ''Benommenheit"  (dullness)  differentiates 
such  conditions  from  affectful  depression  with  re- 


274  BENIGN  STUPORS 

tardation.  He  writes,  of  course,  mainly  of  dementia 
praecox,^^  but  makes  some  remarks  germane  to  our 
problem.  In  the  first  place  he  denies  the  existence 
of  stupor  as  a  clinical  entity,  except  perhaps  as  the 
quintessence  of  '^Benommenheit";  it  is  the  result  of 
total  blocking  of  mental  processes.  Consequently, 
he  says,  one  can  observe  the  external  features  of 
stupor  in  all  akinetic  catatonics,  in  marked  depres- 
sive retardation,  when  there  is  a  lack  of  interest, 
affect  or  will,  in  autism,  with  twilight  states,  as  a 
result  of  negativism  or,  finally,  when  numerous 
hallucinations  distract  the  patient's  attention  into  a 
world  of  fancy.  He  notes  that  in  all  stupors  (with 
the  exception,  perhaps,  of  "Benommenheif )  the 
symptoms  may  disappear  with  appropriate  psychic 
stimulation  or  that  some  reaction,  no  matter  how 
larval,  may  be  observed.  He  speaks,  for  instance, 
of  the  visits  of  relatives  waking  the  patient  up. 

His  only  real  group  is  '^Benommenheit,''  which 
he  separates  out  as  a  true  clinical  entity.  This  seems 
to  correspond  roughly  with  our  ^'Partial  Stupors." 
It  is  essentially  an  affectless,  thinking  disorder, 
usually  acute,  sometimes  chronic,  occurring  among 
schizophrenics.  He  believes  that  it  is  the  result  of 
some  organic  process  (intracranial  pressure  or 
toxin).  Activity  is  much  reduced  or  absent;  they 
have  poor  understanding,  answer  slowly  or  con- 
fusedly; their  actions  are  sometimes  as  ridiculous  as 
those  of  people  in  panic  (e.  g.,  throwing  a  watch  out 

"'^Dementia  Praecox  oder   Gruppe   der  Schizophrenie. ' '     Aschaf- 
fenburg's  ''Handbuch  der  Psychiatrie. ' ' 


THE  LITERATURE  OF  STUPOR  275 

of  the  window  when  the  house  is  on  fire) ;  the  defect 
is  best  seen  in  writing,  for  large  elisions  are  found 
in  sentences.  He  was  able  to  analyze  only  one  case 
and  she  retained  her  affect;  it  was  even  labile  and 
marked.  One  suspects  that  such  a  case  might,  per- 
haps, not  really  find  a  place  in  the  "Benommenheit" 
group  even  as  Bleuler  himself  describes  it. 

With  the  exception  of  Kirby,  whose  work  has  al- 
ready been  discussed  in  the  introduction,  we  have 
been  able  to  find  only  one  author  who  has  attempted 
any  symptomatic  discrimination  of  the  recoverable 
and  malignant  catatonic  states.  Eaecke  ^'^  made  a 
statistical  study  and  found  that  15.8%  recovered, 
10.8%  improved,  54: A%  remained  in  institutions, 
while  30%  died.  With  the  etiology  mainly  exoge- 
nous 20%  recovered  and  14.3%  improved.  A  good 
outcome  was  seen  in  30.2%  of  hereditary  cases, 
while  only  22.7%  did  well  in  the  non-hereditary 
group.  His  most  important  contribution  is  in  his 
formulation  of  good  and  bad  symptoms.  He  thinks 
that  dull,  apathetic  behavior  with  uncleanliness  and 
loss  of  shame  are  not  so  unfavorable  as  has  been 
thought.  Malignant  symptoms  are  grimacing  with 
prolonged  negativism  but  without  essential  affect 
anomaly,  decided  echopraxia  and  echolalia  and 
protracted  catalepsy.  We  would  agree  with  this, 
although  command  automatisms  have  not  been 
prominent  either  in  our  benign  or  malignant 
stupors. 

"Raecke:   "Zur  Prognose  der  Katatonie. "     Arch.  f.  Psychiatrie, 
Bd.  XLVII,   1,  1910. 


276  BENIGN  STUPORS 

Two  writers  have  made  special  observations  that 
should  be  confirmed  and  amplified  before  their  sig- 
nificance can  be  established.  Whitwell  ^^  thinks  that 
in  addition  to  a  diminished  activity  of  the  heart 
there  exists  a  pathological  tension.  Ziehen  says  that 
he  also  has  frequently  seen  angiospastic  pulse- 
curves  in  exhaustion  stupor  or  acute  dementia,  but 
that  other  pulse  pictures  may  be  seen  as  well.  Any 
such  studies  should  be  correlated  rigorously  with  the 
clinical  states  before  they  can  have  any  meaning. 
Wetzel  ^^  tested  the  psychogalvanic  reflex  in  stupors 
and  in  normal  persons  who  simulated  stupors.  He 
found  them  different. 

Only  one  publication  has  come  to  our  attention  in 
which  an  attempt  is  made  at  psychological  interpre- 
tation of  various  symptoms  in  stupor.  Vogt  ^^  de- 
rives much  from  a  restriction  of  the  field  of  con- 
sciousness. Only  one  idea  is  present  at  a  time,  hence 
there  is  no  inhibition  and  impulsiveness  occurs. 
Similarly,  if  the  idea  appear  from  without,  it,  too, 
is  not  inhibited,  which  produces  the  suggestibility 
that  in  turn  accounts  for  catalepsy.  Stereotypy  and 
perseveration  are  other  evidences  of  this  narrow- 
ness of  thought  content.  Negativism  is  a  state,  he 
says,  of  perseverated  muscular  tension.  [This 
would  apply  only  to  muscular  rigidity.]    So  far  as  it 

1^ Whitwell:  ''A  Study  of  the  Pulse  in  Stupor."  Lancet,  Oct. 
17,  1891.     Eeviewed  by  Ziehen,  Neurol.  CentraTbl,  1892,  S.  290. 

"Wetzel:  ''Die  Diagnose  von  Stuporen. "  Baden-Baden  Meeting 
of  May,  1911.     Eeported  in  Neurol.  CentraTbl,  1911,  S.  886. 

^  Vogt,  Ragner :  * '  Zur  Psychologic  der  Katatonischen  Symptome. ' ' 
CentraTbl.  filr.  NervenheilTcunde,  1902,  S.  433. 


THE  LITERATURE  OF  STUPOR  277 

goes,  this  view  seems  sound.  Of  course  it  leaves 
the  problem  at  that  interesting  point,  Why  the  re- 
striction of  consciousness! 

If  stupor  be  a  psychobiological  reaction,  it  should 
occur,  occasionally,  in  organic  conditions  just  as  the 
deliria  of  typhoid  fever  may  contain  many  psycho- 
genic elements.  Gnauck  ^^  reports  such  a  case.  The 
patient,  a  woman,  was  poisoned  by  carbon  dioxide. 
At  first  there  was  unconsciousness.  Then,  as  she 
became  clearer,  it  was  apparent  that  she  was  clouded 
and  confused.  She  soiled.  Neurological  symptoms 
were  indefinite;  enlargement  of  the  left  pupil,  diffi- 
cult gait  and  exaggerated  tendon  reflexes.  Months 
later  she  was  still  apathetic,  although  her  inactivity 
was  sometimes  interrupted  by  such  silly  acts  *  as 
cutting  up  her  shoes.  After  five  months  she  recov- 
ered with  only  scattered  memories  of  the  early  part 
of  her  psychosis.  What  seems  like  a  typical  stupor 
content  was  recalled,  however.  She  thought  she  was 
standing  in  water  and  heard  bells  ringing. 

Stupor-like  reactions  are  not  infrequent  in  con- 
nection with  or  following  fevers.  Bonhoeffer  ^^  de- 
scribes a  type  that  follows  a  febrile  Daemmerzu- 
stand  of  a  few  hours  or  a  day  at  most.  The  affect 
suddenly  goes,  disorientation  sets  in.  Although 
outbreaks  of  anxiety  may  be  intercurrent,  the  domi- 
nant picture  is  of  stupor.     Reactions  are  slowed, 

"Gnauck,  K. :  ''Stupor  nach  Kohlenoxydvergif  tung "  (Charite- 
Annalen,  1883,  p.  409).  Eeviewed  by  Moeli,  Neurol.  CentraTbl.,  1883, 
S.    237. 

^Bonhoeffer:    ''Die   Symptomatischen   Psychosen, "    1910. 


278  BENIGN  STUPORS 

often  there  is  catalepsy.  Sometimes  there  is  a  re- 
tention defect  and  confabulation  to  account  for  the 
recent  past.  Again  the  retention  may  be  good.  In 
the  foreground  stands  a  strong  tendency  to  per- 
severation. This  may  affect  speech  to  the  point  of 
an  apparent  aphasia  or  produce  paragraphia. 
Plainly  organic  aphasia  and  focal  neurological 
symptoms  are  sometimes  seen. 

As  Knauer  ^^  has  gone  thoroughly  into  the  ques- 
tion of  the  febrile  stupors,  the  reader  is  referred  to 
his  paper  for  a  digest  of  the  literature  on  this  topic. 
Mention  has  already  been  made  in  Chapter  IX  to 
this  publication,  where  the  close  resemblance  of 
these  rheumatic,  to  our  benign  functional,  stupors 
has  been  noted.  Discrimination  seems  to  be  possible 
only  on  the  basis  of  delirium-like  features  being 
added  in  the  organic  group. 

^'  Knauer,  A. :  "  Die  im  Gef olge  des  akuten  Gelenkrheumatismus 
auftretenden  psychischen  Storungen, "  Zeitschr.  f.  d.  ges.  Neurol. 
u.  PsycUatrie,  Bd.  XXI,  S.  491-559. 


INDEX 


absorption,    163 

activity,    reduction    of,    36,    100, 

120 
acute  dementia,  251 
adaptation,  107,  192 
adrenalin,  180 
affect,   9,   22,    32,    44,    113,    116, 

117,  123,^  170 
affect,  dissociation   of,    128,   201, 

205,  237 
affect,  inappropriate,   216,  237 
affect,  poverty  of,  234 
affect,  shallow,  127 
affectlessness,  171,  172 
affects,  combination  of,  245 
agitation,  156 
akinesis,  121 

akinetic  psychoses,  4,  274 
albuminuria,  40 
allied   to    dementia   prsecox,    236, 

260 
allied    to    manic-depressive,    236, 

260 
allopsychic,  135 
ambivalence,  147 
amnesia,     9,     24,     68,     70,     267, 

269 
anergic    or    unconscious    stupor, 

258 
anergic  stupor,  255,  256 
anesthesia,   196,  212,  268 
anger,  118,  139 
angiospastic,  276 
animal,  turning  into,  171 
Antaeus,  190 
apathy,    36,    48,    112,    122,    123, 

151,  152,  163,  181,  195,  225, 

237 
apathy,    resemblance    to    absorp- 
tion, 202 


anxiety,  122,  123,  126,  137,  153, 

162,  166,  198,  226 
apoplexy,  224 

arteriosclerotic  dementia,  80 
attention,   195 
atypical  features,  explanation  of, 

200 
autoerotism,  199 
automatism,  268 

Baillarger,  252 

behavior,   195 

* '  Benommenheit, "  67,  273,  274 

bewilderment,    79,    112,   120,    126 

Bleuler,  67,  273 

blocking,  163 

blood-pressure,  181 

blushing,  9 

Bonhoeffer,  277 

boredom,  247 

bowels,  interest  in,  217 

brain  tumor,  5 

breath,  holding,  62 

Brierre  de  Boismont,  252 

burial.   111,   192 

Calculation,  23,  24 
Calvary,  111 
Cannon,  180 
Cases 

Adele  M.   (Case  24),  220 
Alice  E.,  135,  140,  192 
Anna  G.    (Case   1),  6,   47,  48, 
68,  74,  77,  109,  127,  136,  140, 
145,  147,  183 
Anna  L.    (Case   16),   135,  149, 

158 
Anna  M.,  135 

Annie  K.   (Case  5),  24,  69,  72, 
105,  110,  111,  136,  139,  141 


279 


280 


INDEX 


Cases 

Bridget  B.,  135 

Caroline    de   S.    (Case   2),    11, 

68,  109,  141,  178,  193 
Catherine  H.    (Case  23),   S16 
Catherine  M.    (Case  18),   158 
Catherine  W.    (Case  25),  221 
Celia  C.    (Case  17),  155 
Celia  H.   (Case  19),  167 
Charles  O.,  143,  144,  178 

•    Charlotte    W.     (Case    12),    83, 
106,  112,  113,  116,  127,  136, 

141,  144,  166,  201 
Emma  K.,  71,  140 
Harriett  C,  138 
Helen  M.,  130 
Henrietta  B.,  138,  140 
Henrietta  H.   (Case  8),  42,  74, 

77,   105,   106,   110,   111,   115, 
136 
Isabella  M.,  136,  144,  147 
Johanna  B.,  135,  138 
Johanna  S.  (Case  13),  91,  120, 
.      127,  136 
Josephine  C,  138 
Laura  A.,  71,  77,  135,  138,  140, 

142,  193 

Maggie  H.    (Case  14),  71,  96, 

109,  140,   194 

Margaret  C.  (Case  10),  55,  75, 

78 
Mary  C.    (Case  7),  39,  42,  71, 

74,    77,    121,  .136,    138,    178, 

194 
Mary  D.   (Case  4),  20,  47,  69, 

70,  71,  74,  76,  109,  136,  145 
Mary  F.  (Case  3),  14,  68,  105, 

110,  111,  115,  140,  142,  164, 
183 

Mary  G.,  140,  141 

Meta   S.    (Case    15),    99,    109, 

127,  135 
Nellie  H.   (Case  22),  214 
Pearl  F.   (Case  9),  51,  75,  142 
Eose  S.  (Case  21),  210 
Eose  Sch.  (Case  6),  35,  74:,  75, 

145 
Eosie  K.  (Case  11),  62,  75,  105, 

112,  178 
Winifred  O'M.  (Case  20),  207 


catalepsy,  13,  21,  31,  32,  36,  86, 
94,  95,  102,  115,  128,  143, 
144,  145,  147,  209,  211,  235, 
239 

catatonia,  4,  5,  50,  128,  205,  236, 
261 

catherization,   85,    86,   102 

cemetery,  105,  112 

childbirth,  159 

childhood,   188,   195 

Chotzen,  262 

Christ,  86,  115 

Christian  Science,   150 

circular  psychosis,  5,  126 

circulation,  180 

Clark,  184 

clouding,  67 

Clouston,   258 

cocoon,  109 

coffin,  88,   106,   114 

coma,  176,  223 

concussion,   aerial,   224 

confusion,  163 

constipation,   92 

convent,  117 

convulsive   attacks,    15 

crime,  248 

crucifix,  88 

crucifixion,   86,   106,   114,   161 

crustaceans,   148 

cut -up  idea,  94 

cyanosis,  32,  63,  180 

Dagonet,  3,  249,  250,  253,  254, 
258 

death,  feigned,  5,  83,  137,  196, 
246 

death,  mutual,   192 

death,  projected,   198 

death,  relation  with   affect,   110 

death  ideas,  3,  46,  47,  50,  52, 
58,  65,  83,  97,  104,  107,  109, 
110,  111,  114,  115,  119,  122, 
136,  137,  138,  152,  153,  156, 
159,  163,  166,  187,  190,  191, 
192,  199,   212,  225,  235,  240 

death  of  others,  192 

deep  stupor,  I,  6,  41,  199 

deep  stupor,  explanation  of,  197 

Delasiauve,  253 


INDEX 


281 


delirium,  176 

delusional  stupor,  255,  256 

delusions,   165 

delire  melaneholique,   252 

dementia   prsecox,   4,    5,    62,    123, 

127,  128,  205,   225 
depression,  5,  117,  123,  137,  156, 

236,   253 
depression,  differentiation  of,  48, 

124,  226 
dermatographia,  102,  180 
deterioration,  210 
diabetes,  224 
diarrhea,  45,  64,   178 
dissociation,  225 

distress,   119,   122,    154,   156,   162 
dreams,  161,  190 
drooling,  132,  181 
drowning,   87,    192 

Earth,  107,  111,  190 

echolalia,  275 

echopraxia,  275 

ecstasy,  91,   162,   191 

elan  vital,  123 

elation,  44,  91,  123,  127,  151,  157 

electric  chair,  85,   110,   119 

electricity,  150 

emaciation,  8,  32,  58 

emotion,  62 

emotion,  inconsistency  of,  126 

emotions  and  contact  with  reality. 

164  ^' 

energy,  187,  194 
epilepsy,    5,    183,    199,    224,    242. 

254 
epileptic  aura,  184 
epileptic  confusion,  80 
epileptic   deterioration,  80 
erotic,  161 
erotic  ideas,  90 
Esquirol,  251 
Etoc-Demazy,  251 
Euripides,  2 

excretion,  habits  of,  230 
extroversion,  195 

family  visits,  232 
father,  104,  109,  110 
fear,   111 


fever,   8,    13,   26,   32,   38,   40,   45, 

64,   102,   160,  176,  235,   241 
filthiness,  210 
fire,   151,  157 
flippancy,   129 
flushing,   27,    127,    128,    180 
food,  refusal  of,  99,  104 
Eorel,  182 
Proederstrom,  265 

Gadelius,  267,  268 
Ganser  reaction,  263 
Georget,   251 
German  psychiatry,  259 
Gnauck,  277 
giggling,  206 
God,  115,  160,  162 
Golden  Age,  187 
Gregor,  265 
Gucci,  271 
guilt,  157 

hair,  loss  of,  32,  58,  180 

heat    production    and    loss,    179, 

181,  242 
Heaven,    87,    88,    104,    106,    108, 

109,  111,  114,  115,  117,  118, 

160,  162,  166,   171,  191,  240 
Hell,  240 
Hoch,  164 
hypersemia,   8 
hyperesthesia,  268 
hypochondria,  225,   253 
hypomania,   243 
hypnotism   (see  mesmerism),  145. 

213 
hysteria,    3,    135,    184,    225,    264, 

267,  269 

ideational  content,   82,   235 

immobility,   85,   94,   196 

immorality,   150 

impulsiveness,   50,   113,    128,    172 

impurities  in  stupor  reaction,   66 

inaccessibility,    141 

inactivity,  17,  30,  40,  48,  56,  62, 
88,  97,  102,  123,  13S,  152, 
163,  194,  225,  234,  238 

inactivity,  patients'  explanation 
of,   134 

incest  ideas,  ^9 


282 


INDEX 


inconsistency    of    reaction,     134, 

214,  215,  245 
incontinence     (see    wetting    and 

soiling),  52,  57 
indifference,  123,  124,  142 
infantile  reactions,  196 
infections,  5,  173,  241 
insight,   157 
insomnia,  39 
instinct  of  self-preservation,  188, 

191,  198 
interest,  99,  195 
internal  secretions,    178 
internal  thoughts,  163 
interruptions  of  stupor,  130,  197, 

238,   244 
introversion,  164,  227 
involuntary  nervous  system,  178, 

180 
involution  melancholia,  129,   195, 

225,  226 

jaundice,  21 
Jung,  107 

Kahlbaum,   4,   260 

Kirby,  4,  6,  164,  234 

Knauer,  175,  278 

KraepeUn,  4,  260,  269,  271,  272, 

273 
Kutner,  262 

laughter,  56,  141 

Leroy,  269 

leucocytosis,  8,  13,  40,  64,  178 

levels,  principle  of,   198,   244 

Lowenstein,  264 

MacCurdy,  2,  184 

make-up,  mental,  5 

malignant  stupors,  S05 

mania    (or   maniic),    5,    126,    137 

mania,  absorbed,  125,  226,  245 

manic  content,  166 

manic-depressive     insanity,     149, 

167 
manic-depressive   insanity,   mixed 

conditions  in,  202 


manic-depressive  insanity,  path- 
ology of,  174 

manic  episodes,  191 

manic  stupor,   125,  245,   253 

marriage,   160,   169 

masturbation,  196,  209,  219 

melancholic  or  conscious  stupor, 
258 

memory  (see  thinking  disorder), 
40,  67,  168,  195 

menstruation,  8,  56,  61,  100,  168, 

132,  236,  242 
mesmerism,  86,  114,  117,  141,  144 
Meyer,  Adolf,   260 

Meyer,  E.,   261 

midday  nap,  247 

mixed  conditions,  202,  273 

Moeli,  264 

Moses,  108 

mother's  body,  108 

movement,  spontaneous,  133 

muscular  resistiveness,  224 

mutism,    10,    22,    31,    57,    62,    88, 

104,  124,  134,  209,  271 
mutual  death,  165,  192,  196,  248 
Myers,  270,  271 
mystics,  3 
mythology,  107,  108,  190,  240 

negativism,  5,  31,  52,  56,  65,  128, 

133,  139,  199,  209,  225,  235, 
238,  243,  276 

negativism,  explanation  of,   196 
nephritis,  224 
neuropsychic    defect,    174 
neurotic,  150 
nervous,  159 

Newington,  3,  254,  255,  257 
Nirvana,  166,  188,  200,  248 
nourishment,  229,  242 

(Edipus,  165 

oestrous  cycle,  182 

onset,  96 

onset,  depressive,  99 

ophtalmic  disease,  230 

Orestes,  2 

organic  delirium,   175 

organic  dementia,  67 

organic  stupor,   223 


INDEX 


283 


orientation  (see  thinking  dis- 
order), 9,  53,  154,  156,  159, 
170,  245 

Osiris,   108 

pain,  133 

Papanicolaou,   182 

paragraphia,  80 

paralysis,  feeling  of,  105 

paralysis,  general,  5,  254 

partial  stupor,  34,  206 

perplexity,  125,  152,  153,  154, 
155,  156,  160,  162,  164,  165, 
169,  172,  208,  226,  245 

perplexity,  differentiation  of,  227 

perseveration,  145,   148,   276 

personality,  1 

perversity,  138 

physical  disease,  175 

physical   symptoms,   174,   176 

Pinel,  249,  251 

poison,  97,   172 

primitive  ideas,  108 

prison,  105,  169 

prognosis,  4,  5,  206 

prostitution,  157,  161 

psychoanalysis,  161 

psychobiological  reaction,  246 

psychogalvanic  reflex,  276 

psychological  explanation,    186 

psychological  factors,  175 

pulse,  63,  92,  128,  180 

Rank,  107 

reality,  107,  187 

recuperation,  189 

rebirth,  107,  110,  114,  115,   119, 

120,  121,  122,  187,  189,  190, 

191,  240 
regression,    187,    188,    191,    192, 

194,  198,  199,  243 
religious  visions  or  ideas,  2,  162 
resentment,  98 
resistiveness,    54,    97,    102,    112, 

127,  129,  133,  141,  147,  156, 

211,  225 
respiration,  180 
resurrection,   159 
restlessness,  53,  120,  169 
retention  of  urine,  224,  230 


rheumatism,  175 
rigidity,  muscular,  142,  179 
Romberg  sign,  262 
rousing,  176 

sadness.   111,   113,   121,   122,   124 

St.   Catherine  of  Siena,  2 

St.  Paul,  2 

saliva,  30,  63,  181 

scattered  speech,    207,   208 

schizophrenia,   67,   214 

seclusiveness,  207 

secondary  stupor,   259 

Seelig,  263 

self -injury,  50,  57 

sexual  excess,  251,  253,  258 

sexual  ideas,  209,  219 

sexual  sensations,  209 

ship,  87,  106,  118 

sick,    136 

skin,  dry,  180 

skin,  greasy,  43,  180 

sleep,  188,  189,  247 

slowing  of  thought,  125 

slowness,  85,   119,   160 

smearing  of  feces,  142 

smiliiig,  127 

social  status,  236 

soiling,   30,    132,    172,    196,    225, 

230,  235 
somatopsychic,  135 
sphincters,  control  of,  133 
spirits,  89 

spoiled   child   reaction,    129,    139 
starvation,  182 
stereotypy,   276 
Stern,  261 

stimulation,  mental,   231,  246 
Stockard,   179,   182 
stubbornness,  142 
stupidity,  93 
stupor,  diagnosis  of,  223 

hysterical,  225 

malignant,  205,   206 

organic,  223 

reaction,  35,  236 

relation     to      manic-depressive 
insanity,  173 
sudden  mental  loss,  71 
suggestibility,    145,    198,    276 


284 


INDEX 


suicidal  impulses,  50,  84,  104, 
116,  118,  128,  172,  230,  235, 
240 

suicide,  188 

sulkiness,  129 

sullenness,  142 

suprarenals,  242 

swallowing,  133 

sweating,   63,    102,    179,    180 

swimming   movements,    94 

syncopal  attacks,   64 

tears,   95,   98,   117,   128,   153 

tense   of   ideas,    116 

thinking  disorder,  22,  31,  37,  39, 

41,   45,   48,    59,    67,   75,   124, 

125,  148,  152,  157,  235,  239, 

247 
thinking  disorder,  explanation  of, 

195 
tongue,   coated,   13 
toxins,  175 
trauma,  5,  224 
treatment,   S^9 

ulceration  of  eyes,  133 
unconscious  ideas,   163 

motives,  186 
unconsciousness,         physiological, 
199,  224,  277 


underground,  240 
understanding,   67 
uneasiness,  93,  94,  95,  121 
unfaithfulness,    97 
unhappiness,   192 
urine,   retention   of,   31 

Villermay,   250 
Vogt,  276 
vomiting,  45 

water,    94,    95,     106,     107,     114, 

120 
weakness,   137,  160 
wealth,  169 
wedding  ring,   117 
weight   (see  emaciation),  38,  52, 

61 
Wernicke,  3,  273 
wetting,    30,    40,    132,    151,    170, 

172,  196,  225,  230,  235 
Wetzel,  276 
whining,  171,  225 
Whitwell,  276 
Wilmanns,  261 
womb,  108 
worry,  110 
writing,  27 

Ziehen,  276 


DATE 


Benign  stupors 


2002184486 


